Long-Term Disability in Arizona
Aug. 16, 2022
You’re working at your job in Arizona and suddenly a physical or mental condition prevents you from carrying out the duties of your position. Fortunately, you have a long-term disability (LTD) insurance policy that you either acquired at work or obtained from a private broker. You apply for your benefits, and then a long process of proving you qualify commences. Maybe your claim is not only put on hold but eventually denied. What do you do?
Applying for benefits and appealing decisions depend in a large part on which type of policy you have. If you obtained your policy through an employer-sponsored LTD plan, then federal law stemming from the Employee Income Retirement Security Act (ERISA) governs everything.
If you purchased from a private disability insurance carrier such as Unum, MetLife, Hartford, Cigna or Lincoln Financial, then your plan might be governed by state law and by the criteria for qualifying established by the issuing company.
A disability claim or appeal is not something that is a simple do-it-yourself (DIY) proposition. Most people are going to need help assembling the evidence and justification for your claim or appeal.
Wherever you are in Arizona, you can rely on my experience with the big insurers and with the ERISA system to strive to prove your claim and prevail in your appeal if you’re denied. Contact me immediately at Victor Peña Law PLLC. Located in Fort Lauderdale, Florida, my firm handles cases in any city throughout the country.
What is Long-Term Disability Insurance?
Most people harbor doubts that any form of disability, mental or physical, will ever prevent them from missing substantial time from work, but the savvy will weigh their options for wage replacement and medical expense coverage if they do.
In fact, the Centers for Disease Control and Protection (CDC) estimates there are some 1.5 million adults in Arizona suffering from some form of a disability. How many of these have LTD coverage is not known, but common disabilities according to the CDC include mobility (11 percent) and cognition (10 percent).
As mentioned earlier, a long-term disability (LTD) insurance policy, whether sponsored by your employer or purchased on your own, can help when you suddenly cannot perform the duties of your job because of a mental or physical condition. Typically, the policies will cover anywhere from 50 to 70 percent of your wages when you become disabled under the terms of the policy.
But “terms of the policy” can largely determine if you qualify. Many policies will contain clauses regarding pre-existing conditions, which prevent collection of benefits for up to one year if your pre-existing condition is the cause for your claim.
Policies vary, but many will also contain provisions regarding “own occupation” and “any occupation.” Some policies will only cover your disability if it prevents you from working in your own occupation – in other words – your current one, and others may only cover you if you cannot perform the duties in any occupation for which your skills, training and experience have prepared you.
More likely, however, is that your policy will honor benefits for being unable to work in your current occupation for up to 24 months, and then will require you to seek work in any occupation for which your background has prepared you. This does not mean you have to go flipping hamburgers, but the insurer will ask you to seek work in a field for which you are uniquely qualified. The insurer may, in fact, require you to undergo a career assessment or evaluation to determine which occupations may still be available for you.
Reasons for Claim Acceptance – and Denial
Acceptance of your claim, as briefly mentioned earlier, will depend on the definitions of disability and pre-existing conditions spelled out in your policy. You need to read the fine print carefully. When it comes to denial, the insurer can cite those provisions, but most likely a denial will be based on several factors, the primary one being your disability doesn’t meet the standards of the policy. Other factors include:
LACK OF SUFFICIENT MEDICAL EVIDENCE: This means that you did not supply enough documentation of your condition when you filed your claim. A doctor’s statement is, of course, the primary element, but insurers generally expect this statement to be backed by test results and other forms of evaluation to show that you cannot truly perform the duties assigned to you. Vocational testimony and even statements by coworkers, family members and friends as to your condition can also help bolster your case.
SURVEILLANCE: Yes, insurers are known to hire investigators to spy on your social media accounts and even follow you about in public to see if what you claimed is matched by your actions. If, for instance, you say your back prevents you from lifting or carrying objects and they find you online or in public dancing away at a nightclub, your claim will definitely be put in jeopardy.
Offsets to Your Benefits
Most insurers will require you to apply for Social Security Disability Income (SSDI) as a corollary to your receiving benefits. When your SSDI benefits commence, the insurer will then offset that income from what they are paying you.
In other words, you will be paid the differential only if your benefits are higher than those of SSDI. If you receive a lump-sum SSDI payment, you likely will be required to repay the previous benefits provided you under LTD coverage. Some insurers will even calculate your SSDI benefits on their own and deduct accordingly whether you apply or not.
Similarly, if your disability condition happened at work and is covered by workers’ compensation, those benefits will also offset your LTD benefits.
Expertise You Can Depend On
Insurers, whether those underwriting employer-sponsored plans or those you purchase on your own, have one thing in common – the bottom line. Therefore, you can expect challenges and setbacks to your claim for LTD benefits. Dealing with the insurance representatives handling your claim can be frustrating and sometimes beyond what you can grasp or do on your own. That’s why it’s essential to have an attorney who’s dealt with these insurers to help you press your claim, or appeal it if necessary.
If you’re filing an LTD claim anywhere in Arizona, or looking to appeal a denial or subsequent decision about continuation of your benefits, contact me immediately at Victor Peña Law PLLC. Located in Fort Lauderdale, Florida, my firm handles cases nationwide, including clients located in and around the areas of Phoenix, Los Angeles, Seattle, New York City, and Chicago.