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What To Expect From the Disability Insurance Claim Process

Suppose you're disabled as the result of a car accident or another type of personal injury. In that case, there's a good chance you'll file an insurance claim for disability benefits. Disability insurance can provide benefits and protection to you as a worker, but obtaining those benefits can be a long and complicated process.

There are various factors affecting the ease of obtaining benefits. These include:

  • The type of disability insurance policy you have
  • Your policy or plan's terms
  • Whether your insurance comes from an employer or is an individual disability insurance policy

This article will walk you through seeking disability benefits from an insurer. It discusses how to file a claim and what to do if your claim is denied. The article also addresses how to appeal a decision regarding your claim.

How To File Your Claim

If you become disabled due to an illness or injury that prevents you from doing your job, the first step to receiving benefits under a disability insurance plan is to file a claim with your disability insurer. This is a separate process from applying for any Social Security disability benefits you might be eligible to receive from the Social Security Administration (SSA).

Filing a claim typically requires you to fill out a form describing your injuries and job responsibilities. You'll also need to provide your salary and other financial information.

Additionally, your doctor must submit a statement. That statement must:

  • Detail your injury
  • Describe your treatment plan
  • Verify that you're not able to return to work with your current injury

Once your claim is submitted, the insurance company may approve it and begin disbursing benefits. The insurance company may also deny your claim.

What To Do if Your Claim Is Denied

Although disability insurance is intended to help you in your time of need, your disability insurer may deny your claim for several reasons. Your claim may be rejected because:

  • Your particular medical condition isn't a qualifying disability under your policy
  • You missed the deadline for filing your claim
  • Your insurer doubts your doctor's conclusions regarding your claimed disability

So, what happens if your claim is denied? The answer depends on the type of disability insurance at issue and the policy terms. Suppose your disability insurance coverage is through an employee benefits package. In that case, federal law requires you to follow a strict administrative process for appealing a denial before filing a lawsuit.

On the other hand, if you bought private disability insurance through an insurance broker, you're subject to the terms of that policy. Your policy may allow you to file a lawsuit demanding benefits immediately. You may also need to go through an administrative appeal process first.

Your insurer is required to act in good faith when reviewing your claim. If the insurer fails to do so, you can bring an action against the insurer for bad faith denial of your claim.

The Importance of an Administrative Appeal

Whether you're required by federal law to follow an administrative appeal process or follow a disability insurance policy's terms, you can usually appeal before resorting to litigation. The appeals process often requires you to follow specific guidelines and strict deadlines. Failing to do so can lead to the denial of your appeal, which prevents you from being able to have your case heard again by the courts. Following the appeals process correctly is often the only way to retain your rights.

The claims and appeals process can sometimes make or break your later case in court. If you bring your case before a judge, the judge may be required to decide your case based solely on the information in your file. The appeal may be the only chance you have to challenge a denial. This involves using letters or reports from employers, doctors, psychologists, or other experts.

Filing a Lawsuit After a Failed Administrative Appeal

The type of lawsuit you can file following a failed appeal may differ depending on whether you have employer-provided disability insurance or your own insurance policy. If you have private insurance, you can usually file a standard lawsuit with a trial where you present evidence and call witnesses. In contrast, a lawsuit regarding employer-provided disability insurance is controlled by federal law.

In either case, a judge may give the most weight to the information within your file. Your file will contain all the documents and paperwork for your claim and appeal. This is why providing as much supporting information as possible during the administrative appeal process is so important. If you fail to obtain medical records and letters from doctors or other experts, you may limit the evidence a judge can consider in deciding your case.

Ensuring Coverage for Long-Term Disability Claims

Suppose you're successful in obtaining disability insurance benefits following an appeal or after a lawsuit. You must still carefully monitor the terms of your policy to ensure ongoing eligibility for long-term disability coverage. After two years of continuous disability, insurers often deny further disability payments due to changes in insurance policies.

When you file your initial disability insurance claim, you must show you can't perform your specific job. However, after two years, many insurance policies change this requirement to force you to show you can't do any job. As you can imagine, this can be difficult to establish unless you have catastrophic injuries.

If there isn't adequate support in your file to show you can't work any job, your disability insurer may send another denial letter. If this happens, you may face the unwelcome prospect of another appeal and lawsuit.

Get Legal Advice From a Disability Attorney

Perhaps you're considering filing a claim with a disability insurer after sustaining car accident injuries or other impairments such as a traumatic brain injury, spinal cord injury, or back injury. In that case, contact a disability lawyer to discuss your legal options and preserve your rights, or speak with an ERISA lawyer if you need help with an employer-sponsored disability benefit claim.

Receiving disability benefits can help ensure you're able to receive proper medical care, pay existing medical bills, and cover future medical expenses for ongoing medical treatment arising from serious injuries. Meeting with a lawyer can also help you determine whether you have a viable personal injury claim. If so, a personal injury lawyer can represent you in your personal injury case or help you obtain a personal injury settlement as an accident victim.

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