If your long-term disability claim is governed by the Employee Retirement Income Security Act (ERISA), you are required to pursue an administrative appeal before you can file a lawsuit against the disability insurance carrier and the long-term disability plan. After your appeal rights have been exhausted, the next step would be to file a lawsuit in federal district court against the insurance company and the long-term disability plan. The law that developed since the enactment of ERISA in 1974 established that a denial of benefits challenged under ERISA’S civil enforcement provision must be reviewed under a de novo standard unless the benefit plan expressly gives the plan administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the plan’s terms. If the plan documents expressly give the plan administrator or fiduciary discretionary authority, the court is required to review your claim using a deferential standard of review.
If you have long-term disability coverage that was obtained through a group plan at work, and depending on which jurisdiction you reside, chances are that the policy grants discretionary authority to the insurance company. This simply means that a federal court reviewing the decision must give deference to the insurance company’s decision applying what is called an “arbitrary and capricious” standard of review. However, many states (i.e., California, Connecticut, Hawaii, Idaho, Illinois, Indiana, Kentucky, Maine, Maryland, New Jersey, New York, South Dakota, and Texas) have outlawed discretionary authority clauses found in group long-term disability plans.
Under the abuse-of-discretion standard, is it more difficult for a claimant to prevail in court? If the claim is subject to a de novo review, “The court simply proceeds to evaluate whether the plan administrator correctly or incorrectly denied benefits.” (Abatie v. Alta Health & Life Ins. Co. (9th Cir. 2006) 458 F.3d 955, 983.). California enacted Insurance Code §10110.6 effective January 1, 2012, which outlawed discretionary clauses in life, health, and disability plans.
Even if a group disability plan has an effective date before January 1, 2012, the policy insuring the plan will become subject to Insurance Code §10110.6 after renewal on the policy’s annual anniversary date after January 1, 2012.
When the Court utilizes a de novo standard of review, the Court evaluates whether the Plaintiff is disabled within the terms of the plan, and after evaluating the persuasiveness of conflicting evidence, decides which is more likely to be true. Kearney v. Standard Ins. Co., 175 F.3d 1084, 1095 (9th Cir. 1999) (en banc); Muniz v. Amec Const. Management, Inc., 623 F.3d 1290, 1295-96 (9th Cir. 2010).
Under a de novo standard of review, it is the Plaintiff’s burden to prove their disability by a preponderance of evidence. Muniz v. Amec Constr. Mgmt., 623 F.3d 1290, 1294 (9th Cir. 2010). This means it is the Plaintiff’s responsibility to produce evidence demonstrating that the plan administrator incorrectly denied benefits. The evidence must establish that the claimant satisfies the definition of disability in the policy. See Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 963 (9th Cir. 2006). Essentially, it is the court’s duty to determine whether or not the evidence supports disability.
If you are dealing with a disability claim that has been denied by an insurance company, contact the Law Offices of Kevin M. Zietz for a free consultation.
If Long-Term Disability (LTD) coverage is offered through an employer-sponsored program available at your place of employment, most group LTD plans will contain a “pre-existing condition” exclusion. These types of policies are not underwritten for each of the individuals in the group, so pre-existing condition exclusions are designed to prevent the insurance company that funds the group LTD plan from insuring someone who immediately presents a claim as soon as their coverage takes effect. The insurance company does not look at the medical history of every member in the group before insuring them, so the company does not know what the risk is of providing each individual with insurance coverage. Insurance companies want to avoid paying out claims to people who obtain employment with the sole purpose of securing LTD coverage so they can immediately make a claim.
Have you made a claim for LTD benefits within the first 12 months after you became insured under your employer’s group disability plan?
The pre-existing condition exclusion will apply if you make a claim for LTD benefits within the first twelve months after you become covered under the plan. While this time period could vary, typically it is the one-year period after the effective date of coverage. If you submit a claim for benefits within this one-year time frame, that will trigger a “pre-existing condition investigation” by the insurance company.
What is a Pre-Existing Condition Investigation?
The insurance company will review all the medical information provided in support of your LTD claim after receiving an application for benefits. If the medical records demonstrate that you consulted with a doctor, had treatment, were prescribed medication, and/or had diagnostic testing, for symptoms related to your disabling medical condition (physical or mental) during the specified time before your LTD insurance went into effect, the insurance can deny your claim based on the pre-existing condition exclusion.
The purpose of a “pre-existing condition investigation” is to evaluate your health just before you’re the effective date of your LTD coverage. This will involve a request for all medical records for the relevant time period. The time period will vary depending on the policy (so be sure to check the specific policy wording in your policy), but it is usually for the period 90 days prior to the effective date of your coverage. For example, if your coverage became effective on January 1, 2023, the insurance company will look back at the window between October 3, 2022, and December 31, 2022. This period of time is what is typically referred to as the “look back window.”
Determining Whether a Condition Will Be Excluded as “Pre-Existing” is Not Always Clear.
In 2019 and 2020, we represented an individual who had a long psychiatric history that included evaluation and treatment related to attention-deficit/hyperactivity disorder (ADHD), generalized anxiety disorder, and insomnia. He in fact saw a psychiatrist related to these conditions during the 90-day look-back window so the insurance company denied his LTD claim on the basis that his claim was excluded by the pre-existing condition provision in the applicable policy.
During the administrative appeal process, we provided the insurance company with medical documentation establishing that the current LTD claim being pursued was based upon impairment(s) caused by major depressive disorder and agoraphobia. We convinced the insurance company that while our client did have a significant psychiatric history, he did not consult with a mental health professional or seek any treatment or evaluation for major depressive disorder and/or agoraphobia during the 90-day look-back window. The insurance company reversed the decision to deny the claim based upon the application of the pre-existing condition exclusion and paid the claim.
If you are dealing with a denial of LTD benefits because the insurance company determined that a pre-existing condition clause in the group LTD policy excludes your claim, please contact attorney Kevin M. Zietz for a free consultation.
A portion of your pay is reduced from your paycheck by your employer. This money goes toward Social Security benefits, which you pay into for all the years you work and earn wages. While many people end up using their Social Security toward their eventual retirement, another benefit that comes from it is Social Security disability insurance.
Social Security disability insurance is in place in the event that you suffer a serious long-term or even permanent disability that prevents you from working. If you become disabled, you have the right to file a disability claim with the Social Security Administration or SSA to get monthly payments.
Unfortunately, although millions of people suffer from disabilities each year and apply for Social Security disability benefits, things are not always black and white. One thing that can happen is that you are denied benefits in spite of your legitimate disability status.
When Social Security Disability Benefits Claims are Denied
Each year, around 66 percent of all California residents applying for Social Security disability benefits have their claims denied by the SSA. If this happens to you, it’s no doubt a scary situation as you are unable to work and earn a living. It’s fair to wonder how you will be able to get by financially. However, if your application is denied, there are steps you can take to make an appeal. You can still end up getting disability benefits. One thing you can do is to contact a Los Angeles denied disability attorney for help.
Why Do Social Security Disability Claims Get Denied?
There are various reasons why your Social Security disability claim might be denied. First-time applications are often denied, but it’s important to know why this is the case as it can help you in the future.
If you are denied benefits, the SSA will send you a letter explaining the reasons behind the decision. There will also be steps in the letter that explain how you can appeal that decision.
The following includes the most common reasons why a Social Security disability claim is denied:
Insufficient medical evidence: The chief reason for a claim being denied is insufficient medical evidence. You must prove that you are unable to work for at least 12 months, which means you should include all the pertinent documentation, tests, treatments, and anything else relevant to your condition.
Substantial gain activity or SGA: If you earn more than the SGA, your application will be denied. Your income cannot be higher than the amount of benefits you would receive.
Neglecting to follow treatment plan: Not following the doctor’s treatment plan can result in a claim denial. The plan serves as proof that you are unable to work due to your condition.
Ignoring requests: Your claim can be denied if you ignore requests for additional documentation.
Refiling a claim: You can also be denied if you were previously denied and refiled a claim for benefits. You should appeal instead of filing a new claim.
Reconsideration of Denied Social Security Disability Claims
California recently instituted a reconsideration of denied Social Security disability claims. This policy means that claims that were previously denied will be re-reviewed for consideration. However, this only applies to individuals who have chronic or debilitating medical conditions such as terminal cancer.
Filing an Appeal of Denial of Your Claim
If your claim was denied and you do not have a chronic or debilitating medical condition, you can still appeal the decision. It’s important to know that it can take months or even years before your application is re-evaluated, but you can retain a Los Angeles disability lawyer to assist you. In some cases, you may even learn that your claim was denied simply due to a mistake you made on your application.
In most cases, you only need to deliver additional documentation to the SSA when you file your appeal. The best thing you can do is have legal counsel on your side. If you need a disability attorney Los Angeles has plenty of highly professional, experienced options for you. Having a denied disability attorney in Los Angeles can make a huge difference in the outcome of your appeal.
You will have to submit additional or even new medical evidence and a Residual Function Capacity or RFC form, which must be filled out by your doctor. It’s strong evidence that helps to support your disability claim.
There may also be a disability hearing where a judge will hear why you deserve Social Security disability benefits. Your attorney can help you here as well. You will also be required to answer questions posed by a medical expert.
If the denial of your claim is not overturned, the decision then goes to the Appeals Council and a new judge will review your case. This can lead to the previous decision being overturned.
If you are in California and have your Social Security disability benefits claim denied, you need the Law Office of Kevin M. Zietz on your side. You will have the opportunity to discuss your case with an experienced Los Angeles disability attorney and have a better chance during your appeal.
Long-term care (LTC) insurance covers the costs of nursing home and/or assisted living services. Under most long-term care policies, a person is eligible for benefits when they are not able to do at least two out of six “activities of daily living” without the assistance of a home health professional, or they suffer from dementia or other cognitive impairment. The activities of daily living are:
- Bathing.
- Caring for incontinence.
- Dressing.
- Eating.
- Toileting (getting on or off the toilet).
- Transferring (getting in or out of a bed or a chair).
LTC insurance is expensive. According to the Alzheimer’s Association, the estimated cost for end-of-life care in 2019 ranged between $233,000 and $367,000. Most health and disability insurance will not cover long-term care, but long-term care insurance will.
Long-term care insurance policies may have limits on how long or how much they will pay. Some policies will pay the costs of long-term care services for two to five years, while other insurance companies offer policies that will pay for a person’s long-term care costs for as long as they live, regardless of cost.
Unfortunately, in the ongoing effort to cut their costs, insurance companies routinely deny valid LTC insurance claims based on technical requirements in the policies. Insurance companies also deny LTC claims by disputing that a person’s medical condition requires the level of care covered by the LTC policy, or by suggesting that those seeking benefits are receiving more care than is necessary or have been placed in the wrong type of facility.
If you have questions about what your options are after an insurance company has denied a claim for LTC benefits, call attorney Kevin M. Zietz for a free consultation.
