Indiana Long Term Disability Lawyer Blog

Multiple Sclerosis is an autoimmune disease that affects the brain and spinal cord. The symptoms and severity of Multiple Sclerosis (MS) can vary among those afflicted with the disease, but it is not uncommon for the condition to prevent a person from working. Symptoms can include fatigue, loss of balance, muscle spasms, numbness, weakness, tremors, problems with coordination, difficulty walking, vision problems, bowel/bladder difficulties, inability to concentrate, memory problems, and speech impairments.

When MS prevents a person from working and they file a disability claim with their insurance company or the Social Security Administration, there are a few things that can help prove that MS is disabling. The first step is to make sure that the patient has been diagnosed properly. That includes undergoing exams like MRIs of the brain and spine, nerve function studies, and lumbar punctures. These objective test results are essential to ruling out other conditions and determining whether a patient has MS. Moreover, these test results can also indicate the severity level of a patient's MS.

Continue reading "Multiple Sclerosis Disability Claims" »

The application process is generally quite simple. First, you must notify your insurance company or your Human Resources department of your claim. You will then be asked to complete a claim form and to sign a medical authorization form so that the insurance carrier may request copies of your medical records directly from any doctors who have treated you for your conditions. Your doctor will also need to fill out a form certifying that you are unable to return to work because of your medical conditions. Lastly, your employer must complete a form providing the insurance company with your position and salary information so that they may properly calculate your monthly benefit payment.

As part of their investigation, the insurance company may also send you to one of their doctors to examine you in order to determine if you are able to return to work or send you to a functional capacity evaluation to assess your physical capabilities.

If your claim is approved, your long term disability policy typically will pay you 60% of your wages while you are disabled, depending on the specific terms of your policy. Your insurance company will require periodic updates on your condition, from both you and your physicians, to verify that your disabling condition is ongoing. In some instances, the insurance company may hire an investigator to conduct surveillance of your activities while you are away from your job and possibly conduct an internet search to uncover your volunteer or social activities.

If your claim for benefits is denied, there are options available to you if you do not agree with the insurance company's decision. This will depend on your policy, but typically you will have the opportunity to file an appeal, usually within 180 days of the denial. During the appeal process, you will be able to submit further medical evidence of your disability. This is one reason why it is important to continue treating with your doctor while you are off of work.

In a perfect world, your long term disability insurance carrier will pay your claim until you are well enough to return to work or until your maximum coverage age of 65 if you are deemed totally disabled and cannot return to work. However, if your claim is denied, please contact the O'Ryan Law Firm to see if we can assist you in convincing the insurance company to properly pay your disability benefits.

Fibromyalgia is a condition that may prevent someone from working. In these situations, the person may be able to apply for short term disability benefits, long term disability benefits, or Social Security disability benefits. When it comes to filing a claim for disability benefits, it can be challenging for claimants to prove that their fibromyalgia is disabling. These challenges appear in claims to both insurance companies and the Social Security Administration ("SSA").

Those who suffer from fibromyalgia experience chronic, widespread pain and fatigue, but the objective test results may not show this. Unlike conditions such as Multiple Sclerosis or degenerative disc disease, fibromyalgia does not appear in MRIs or x-rays. Because fibromyalgia is a disorder which does not appear in medical imaging or blood tests, it can be a difficult condition to diagnose. If a fibromyalgia patient is applying for disability benefits, they should follow these steps to document proof of their disability:

Continue reading "Fibromyalgia Disability Claims" »

The most basic answer is that the insurance company or claims administrator contends that you do not meet the definition of "disabled" or "disability" under the disability policy or plan. There are numerous technical reasons why claims are denied such as you are ineligible for benefits or you have not provided the information requested by the insurance company. As far as being ineligible, many disability policies require that you work so many months for your employer before you become eligible for the short or long term disability coverage. Also, you may no longer be eligible if your employment has been terminated and you have not already applied for the benefits. We encourage our clients to contact the Human Resources department immediately to obtain an application for short term and long term disability benefits when they know that they are no longer able to function at their job. Additionally, make sure that you send the insurance company all of the information and documents that they are requesting so that your claim is not tossed out because they didn't receive a specific form or medical record. We know that at times it is frustrating dealing with their seemingly endless requests, but you don't want to be denied because you "weren't cooperating" with them, which is a requirement in the policy.

Once you have made it over the eligibility hurdle, the insurance companies find all sorts of reasons to deny disability claims: your medical records don't support impairment, your doctor's statement of disability doesn't comport with the medical records, you worked for a long time after you were diagnosed, surveillance shows that you remain active, if you can work on a computer at home then you aren't disabled, if you can shop at Wal-Mart then you can go back to work, you quit because you didn't like your boss and their absolute favorite: our doctors (who never speak to you or examine you) say you can work. All of the insurance companies, including Cigna, Prudential, Hartford, MetLife, and Lincoln Financial, like to use their doctors to review and deny claims.

This is why the appeal process is so important and why an experienced lawyer can make all of the difference. This is no game to the insurance companies. They know that if they successfully deny your claim, they keep every penny of your disability payments. As a result, they are very aggressive at denying claims and making sure the denial sticks. We take the appeals process very seriously because this most likely is your last chance to respond to and rebut all of the bad information that the insurance company has stuffed into your file, some of which you may have never seen.

Continue reading "Why was my claim denied?" »

If you have been denied short term or long term disability benefits, you may have noticed information in your denial letter about The Employee Retirement Income Security Act of 1974, or "ERISA." ERISA includes regulations for all employee benefits that are offered by private employers, including your group health and disability insurance.

Which Employee Benefit Plans are Covered by ERISA?
ERISA governs most private employee benefit plans, including disability and health insurance plans.

Which Employee Benefit Plans are Exempt from ERISA?
ERISA usually does not cover employee benefit plans offered through public or church employers. If you're an employee of a public school or a church owned hospital, your employee benefit plan may be exempt from ERISA. Additionally, "salary continuation plans" may also be exempt from ERISA.

My ERISA Claim Has Been Denied. Now What?
If your ERISA claim has been denied, you must first file an appeal. ERISA allows the claimant to seek legal representation during the appeals process and O'Ryan Law Firm may be able to help you.

Appeal
ERISA describes the number of days allowed to appeal and also the number of days in which the insurer has to make a decision. During the appeal process, the claimant has the right to request the administrative claim file that the insurance company has created. ERISA law specifies that the employee's claim file must be sent within 30 days of a request.

ERISA law states that a claimant must appeal a denial within 180 days. If a claimant fails to appeal by this deadline, they could forfeit their claim for disability benefits. The appeals process is very important and must contain relevant medical and vocational evidence.

Once the claimant has appealed, the insurance company has a maximum of 90 days to make a determination. If the insurance company's review will take longer than 45 days, then the insurer is to notify the claimant in writing that more time is needed.

Lawsuit
In most situations, the claimant must exhaust the appeals process before they are permitted to file a law suit in court. Because ERISA claims are governed by a federal act, the claimant must file a lawsuit in federal court. The deadline to file a lawsuit is usually included in the employee benefit plan.

Unfortunately, the judge's review of the ERISA claim is generally limited to the evidence that was supplied during the claim review process and appeal. That means that the claimant does not have the chance to submit supportive medical information after their last appeal has been denied. Therefore, the appeal phase is extremely important to a claimant's chances of success.

Additionally, ERISA cases are not entitled to a jury trial. Rather, the judge is the sole determiner of the lawsuit. The judge usually makes his or her determination by reviewing extensive legal briefs by both the Plaintiff and Defendant.

Contact O'Ryan Law Firm
Because the rules of ERISA are complicated and O'Ryan Law Firm has a wealth of experience handling every step of the ERISA claims process, we may be able to help you if you have been denied disability insurance benefits.

The Employee Retirement Income Security Act of 1974, otherwise known as ERISA, regulates employee welfare benefit plans, which include plans that provide employees with benefits in the event of sickness, accident or disability. 29 U.S.C. § 1002(1). The primary purpose behind the enactment of ERISA was to protect workers from the mismanagement by the plan administrator of funds accumulated to finance employee benefits. Stern v. International Business Machines Corporation (IBM), 326 F.3d 1367, 1372 (11th Cir. 2003). However, when an employer pays occasional, temporary benefits from its general assets, there is no benefits fund to abuse or mismanage, and therefore no special risk of loss or nonpayment of benefits. McMahon v. Digital Equipment Corp., 162 F.3d 28, 36 (1st Cir. 1998). To that end, the Secretary of Labor has promulgated a regulation that excludes certain "payroll practices" from ERISA's oversight. That regulation provides that an employee benefit welfare plan shall not include payment of an employee's normal compensation, out of the employer's general assets, on account of periods of time during which the employee is physically or mentally unable to perform the duties of his or her occupation or is otherwise absent for medical reasons. 29 C.F.R. § 2510.3-1(b)(2). Accordingly, many short term disability plans offered by employers are considered payroll practices, which are governed by state law. So long as the disability benefits are paid from the employer's general assets, paid when the employee is absent for medical reasons, and paid as normal compensation, the plan is a payroll practice rather than an ERISA plan.

When an employer fails to pay short term disability benefits as a payroll practice to an employee who meets the plan's terms for eligibility, the employer may be violating one of Indiana's wage statutes. Indiana has enacted two separate wage statutes: (1) the Indiana Wage Claims Statute at I.C. § 22-2-9, and (2) the Indiana Wage Payment Statute at I.C. § 22-2-5-2. The statutes set forth two different procedural frameworks for wage disputes, and each statute applies to different categories of claimants. The Wage Claims Statute references employees who have been separated from work by their employer or whose work has been suspended as a result of an industrial dispute, and such employees must pursue their claims through the Department of Labor. I.C. § 22-2-9. By contrast, the Indiana Wage Payment Statute references current employees and employees who have voluntarily left employment either permanently or temporarily. I.C. § 22-2-5-1(b); St. Vincent Hospital and Health Care Center, Inc. v. Steele, 766 N.E.2d 699, 705 (Ind. 2002).

Violations of short term disability benefits plans (also sometimes known as salary continuation plans) that are payroll practices are subject to the Indiana Wage Payment Act. In addition to payment of the wages, the Act allows for liquidated damages in the amount of two times the unpaid wages and attorneys' fees and costs when an employer fails to make payment of wages. Questions often arise as to whether a particular disability plan is governed by ERISA or is a payroll practice, and employers have the burden of establishing that their short term disability plan or salary continuation plan is subject to ERISA and not, in fact, a payroll practice. An employer's representation that the short term disability plan offered to their employees is an ERISA plan does not necessarily mean that the plan falls within the scope of ERISA. The determination of a plan as an ERISA plan does not rest on the employer's conduct, but rather whether the plan is exempt from ERISA by the payroll practices regulations.

The O'Ryan Law Firm has successfully litigated both ERISA disability claims and payroll practices violations. If you have had salary continuation benefits or short term disability benefits denied or terminated by your employer, contact O'Ryan Law Firm.