Disability Insurance Claims
Many employers provide their employees with employment benefits that may include the right to apply for insured medical and disability benefits in the event the employee suffers an injury or illness that causes an ongoing disability preventing them from returning to their employment. The conditions and terms that determine when benefits are payable to the employee are referred to in some form of an Employment Benefits Plan. The payment of benefits to an employee are usually paid by an underwriter insurer that acts as the Administrator of the Plan and is handled by an adjuster appointed by the Administrator of the Plan to handle inquiries regarding coverage and the payment of benefits under the Plan.
Most Employment Benefits Plans contain coverage for medical benefits that may include coverage for hospital stays, physiotherapy and massage treatments, prescription drugs, dental treatment benefits and psychological treatments.
Most Benefits Plans will provide coverage for up 80% of the necessary expense items although some coverage may limited to a set annual amount that may limit the amount for a particular service in each calendar year.
The Benefit Plan will also set out the requirements for necessary medical or dental documentation recommending the requested service treatment and may require reports of treating professionals to support the claim. Generally a written prescription for medication or therapy is all that is required to request reimbursement for prescribed treatments under a Benefit Plan.
LONG TERM DISABILITY BENEFITS
Long Term Disability Insurance or "LTDI" benefits include payment of a monthly income replacement benefit prescribed for under the terms of Benefit Plan for the payment of Long Term Disability Insurance Benefits.
The costs of premiums for LTDI insurance policies are usually paid for by contributions from by both the employee (through employment benefits deducted from the employee's pay earnings) and the employer often matching the employee contribution.
There are many factors relevant to determining the rights of an individual to the payment of long term disability benefits and discussing with an experienced lawyer is the best way of ensuring that your rights are protected.
Most Employment Benefits Plans provide for sick benefits payable to an eligible employee as Short Term Sick Benefits that are payable from the initial date of disability for 90 days. if the employee remains disabled from returning to work due to illness or injury after the first 90 days the Short term sick benefits usually converts into Short Term Disability Benefits that are payable for up to 24 months so long as the employee is unable to return to doing the work duties for the position with that employer they previously held at the time of the onset of their disability.
Any illness or injury whether, physical or psychological may form the basis for a claim for Short Term and Long Term Disability Benefits.
The Employment Benefits Plan Booklet will set out the areas of illness and injury that the Benefits Plan will cover and any excluded causes.
In general most Benefits Plans will provide Short and Long Term Disability Benefits Plans, will cover, among other incidents, the following :
- disability caused by injuries from motor vehicle accidents, slip and fall accidents or assaults or any other kind of accident that results in the employee suffering physical or psychological injuries that lead to the employee's disability preventing their return to work
- psychological injuries developed by an employee may include illnesses such as depression or other psychotic illnesses, like bi-polar disorders or anything that causes a disability preventing the employee's return to work
Depending on the definitions in the applicable Employment Benefits Plan, after the first 24 months of disability the employee is entitled to Long Term Disability Benefits only if the continuing disability prevents the employee from returning to work within any kind of employment that they are physically capable to doing and that they are suited for and not just their own pre-disability injury position. In other words if an employee working in construction is injured and disabled from returning to work as a construction worker but is after 24 months capable of working in another field they may not be entitled to continued LTDI benefits after the 24 month period.
Since LTDI benefits are payable only for the period the employee is disabled from returning to work the Employment Benefits Plan generally entitles the Administrator of the Plan to require the employee to submit updated medical reports from a physician who is asked to give an opinion on the employee's injury or illness and to give an opinion on their ability to return to work. An employee's failure to submit such requested medical opinions may lead to the discontinuance of future LTDI benefits until the requested information is provided.
After a claim for LTDI benefits is accepted by an LTDI the Administrator is obligated to the payment for ongoing LTDI benefits and these benefits may only be terminated by an Administrator if they have obtained a medical opinion that states that the employee is capable of returning to work. The definition of what "return to work" means is dependent upon the specific wording and terminology used in the Employment Benefits Plan.
After a claim is accepted an LTDI Administrator has the legal onus of proving the grounds for terminating and denying future benefits. In other words the Administrator may not simply discontinue ongoing payment of LTDI benefits based solely upon the opinion of an adjuster of the claim.
Unfair treatment of an employee's claim or denial of a claim for medical or disability benefits under a Plan may give rise to the right to pursue a claim for damages against the Administrator of the Plan, usually an insurance company. Awarded damages may include financial compensation for the amount of withheld payments due and owing when the denial occurred plus interest as well as a declaration of entitlement to the denied benefits either as a declaration of disability or declaration entitled medical or dental or psychological benefits.
Because an Administrator of LTDI benefits may require annual review of the claim to determine future eligibility most Administrator's will offer to settle an employee civil claim for denied LTDI benefits by offering a lump sum cash settlement to cover the value of unpaid benefits. These types of settlements require an assessment of applicable factors referred to as contingencies to determine whether the settlement of future benefits is fair to the employee.
The lawyers in our firm have many years of experience in representing persons with claims for long term disability claims for recovery of benefits withheld by their disability insurers.
If you have been denied long term disability benefits call us to set up an appointment for a free initial consultation to discuss your case.