Disability FAQ’s

Ans. Not before a knowledgeable lawyer thoroughly reviews it.  Insurance carriers rarely do anything voluntarily, unless it is in their financial or legal interests.  Whether to accept a disability claim is a complex issue which should be  thoroughly analyzed by some one who completely understands  the real value of a buyout offer and is working solely for the policyholder.   All pertinent factors, which bear on such a decision must be carefully weighed. Claimants should be wary of a carrier trying to get out from under a claim cheaply by tempting the beneficiary with what appears to be a sizable sum when the beneficiary is hurting and is financially strapped. If you have a question which was not answered to your satisfaction or you would like more information, contact Mike Quiat  or call him toll-free at (800) 797-5575. DISCLAIMER The material on this Web Site is not legal advice. The material is strictly for informational purposes.  Your visit to this Web Site does not create an attorney-client relationship of any kind. (Full Disclaimer)  

Ans. Yes and no, depending on the type of policy the claimant has and the state in which the claimant lives.  Claimants may have state law rights which allow them to have their legal fees reimbursed by the carrier if they win. Most states, including New Jersey and New York, do not provide for these rights for private disability insurance.  However, if you recover punitive damages for a carrier's "bad faith" your legal fees will most likely be covered. If your claim is under a group policy covered by ERISA, such as an employer sponsored Long Term ("LTD") Disability insurance plan, you are entitled to ask the court to reimburse you for legal fees if you are successful in litigating your claim.

Ans. Most disability policies require insureds to submit to an Independent Medical Examination (IME) by doctors selected by the carrier to confirm the diagnosis and the state of impairment. Some also require a Functional Capacity Evaluation (FCE) to determine how the claimant's ilness or injury affects the ability to perform his or her occcupation.  Insureds who do not agree to participate in this process may lose their benefits. However, the insured does have certain rights with respect to the conduct of IMEs and FCEs:

• The right to have a witness present, including an attorney.
• The right to record the session.
• The right to get copies of the reports and underlying test results.
• The right to have IME and FCE exams scheduled at a convenient time and place.
• The right for these tests to be scheduled only as frequently as is reasonable under the circumstances.

Ans. Once a claimant is on long-term disability, most policies provide for a "waiver of premium" which no longer requires premium payments for the duration of the disability. Once the disability ends, premium payments resume.

Ans. Yes. Disability insurance carriers will not pay a disability claim unless a competent medical provider has certified the disability and its impact on claimant's ability to do his or her job.  The physician must not only describe your illness or injury in detail, but must explain to the insurer why the illness or injury prevents claimant from performing his/her job duties.

Ans. This depends in part on whether the policy is a group policy covered by the Employee Retirement Income Security Act (ôERISAö), or is an individual disability income policy. Generally speaking, Courts allow carriers to take a ôreasonableö time to fully investigate a claim before making a determination. What constitutes a ôreasonableö time will depends in large measure on the facts of each case. In ERISA cases, carriers generally have 90 days to decide a claim, but this time period can, and often is, extended for good cause.

Ans. Immediately. Disability claim forms are not like auto or health insurance claim forms. The very specific questions raised by a standard disability insurance claim forms require much thought. Once a claim form is submitted, it is part of the case forever.  Disability insurance claims may stand or fall because of those initial claim forms. To avoid mistakes and pitfalls which can result in delay or denial of legitimate claims, a knowledgeable, experienced disability insurance attorney should assist the claimant in preparing the claim forms before they are filed with the carrier.

Ans. Yes. All disability insurance policies provide for strict timely notice of a claim to the carrier. Failure to give timely notice of the claim, leads to the carrier denying the claim. The claim may be reinstated by a court unless there is real prejudice to the carrier as a result of the delay. Disability insurance claims are hard enough to prosecute, without these types of issues, so it is best to get the timing right the first time.

Ans. Disability insurance companies use varying language in their policies, but generally a claimant must establish that:

• claimant has a medical condition (illness or injury), which is certified to by a competent medical provider;
• claimant is unable to perform their substantial and/or material occupational duties a result of this condition.
• claimant must meet both of these criteria before being eligible for benefits.