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Purchasing short-term and long-term disability insurance policies is a smart decision that protects employees from wage loss in the event of a medical condition that impedes their ability to work. These policies are sometimes offered by employers but can also be purchased privately.
Short-term and long-term disability insurance policies are either paid via a payroll deduction or directly by premium payments and allow the policyholder to continue receiving a portion of their salary while they are disabled.
Employer or Private Insurance
Employer-provided policies may be governed by the federal Employee Retirement Income Security Act (ERISA), which has strict and complex rules for how and when to file a claim or appeal the denial of one. Privately purchased policies are not subject to ERISA; they are administered in accordance with the contractual terms of the policy.
Like Social Security Disability claims, the applicant must prove they are medically unable to perform their job, but the standard for doing so is typically easier to meet for short-term and long-term disability insurance. The claimant need only prove they cannot perform their regular occupation and age is not a factor. The Social Security Administration, by contrast, holds younger applicants to a stricter standard than older individuals.
Policies differ, but most require a six-month waiting period before long-term disability payments commence, and most provide payments until the claimant reaches the age of 65.
However, at any point until that time, the insurance company is permitted to request a review of the claim to evaluate whether the disability has changed or lessened in severity. If their medical experts determine that is the case, they will immediately deny the claim and discontinue payments — unless the claimant successfully sues to overturn that determination.
The definition of “disabled” will be established in the insurance policy, but generally policies define it as being unable to perform a regular occupation.
Claims administrators may be employed by the insurance company and many deny first time claims even if they are justified. Reasons given for denying a claim include (but are not limited to):
- Insufficient medical evidence (such as a lack of regular medical treatment, adequate records, or a doctor’s statement)
- Failure to meet the policy’s definition of disability
- Video surveillance by the insurance company that conflicts with the claim
- Missed application deadlines
Policyholders have a right to appeal a denied claim and any determination that was made in that denial. There are strict deadlines to file appeals, however. Under ERISA and many private policies, the appeal must typically be filed within 180 days.
If the appeal is also denied, the policyholder can file a lawsuit in federal court. There is no right to a jury trial in these cases; a federal judge will review the basis for the insurance company’s decision as well as medical expert opinions and information presented by the policyholder rebutting it. The judge will decide whether there was a rational basis for denying the claim or not.
Social Security Disability
The U.S. government recognizes that illness and injuries, both sudden and chronic, can prevent individuals from continuing in their employment. Social Security Disability Insurance (SSDI) is an insurance program run by the Social Security Administration (SSA) to assist Americans who find themselves medically unable to work.
SSDI is not a handout or a welfare program; it’s an insurance policy that employees contribute to automatically through taxes on their employment income. A percentage of every paycheck is directed to the SSA’s Disability Trust Fund, which disburses those funds to disabled individuals of all ages and employment histories. Any person who is disabled by any medical condition that prevents them from working and meets certain eligibility requirements may apply for and potentially receive SSDI benefits.
Because the application process can be confusing, complex, and unfamiliar to those inexperienced with navigating large bureaucratic institutions, it is highly recommended that applicants find support from legal experts like Pond Lehocky Giordano to guide them every step of the way.
The first step in applying for SSDI benefits is proving the existence of a disability to the SSA. Medical conditions that may result in a determination of disability include (but are not limited to):
- Back pain
- Neck pain
- Shoulder pain
- Hip, knee, or hand issues
- Heart Disease
- Anxiety and Depression
- Crohn’s Disease and IBS
- Multiple Sclerosis
- Parkinson’s Disease
- Chronic Fatigue
Over 70% of individuals are denied SSDI benefits the first time they apply for them. A determined and knowledgeable legal team is essential to streamlining what can be an arduous process that is fraught with potential pitfalls. Additionally, even if an individual has been denied in their application for SSDI, they are entitled to reapply through an appeals process.
SSDI is available to individuals who have paid into the SSA through their taxes for a period of time before becoming disabled. That length of time varies but is generally five of the last 10 years.
However, individuals who have not worked or paid taxes in many years, have only worked for a brief period of time, or who have never worked or paid taxes may still be eligible for a different SSA program called Supplemental Security Income (SSI).
The eligibility requirements for SSI are based on financial guidelines similar to public assistance or welfare. Individuals that are not working or earning less than $1,310 in gross income per month and have a medical condition which prevents or significantly limits their ability to work are eligible.
The SSA takes age into consideration when making determinations for both SSDI and SSI. Individuals between the ages of 18-49 must show they have conditions so severe that they are unable to continue in their prior type of employment or any other type of work in the national economy.
The bar for a successful application is lower for individuals over the age of 50, particularly if the work they previously performed was physical in nature.
If an applicant is approved for SSDI benefits, they may receive:
- Monthly payments
- Retroactive payments (depending on the date disability was determined)
- Health insurance under Medicare within two years of the disability entitlement date
- Additional monthly benefits to any of the applicant’s children under the age of 18