Articles Tagged with “short term disability”

It’s never too early or too late to hire an attorney to represent you in your disability case. You do not have to wait to be denied by your insurance company before talking to an attorney. We offer several services that can protect your interests. Here are some examples of how we can help:

  • Assist you with your initial application for Long Term or Short Term Disability benefits.
  • Help manage your monthly Long Term Disability benefits.

Many Indiana employees receive group disability insurance coverage through Aetna. Headquartered in Hartford, Connecticut, Aetna is a large disability insurance company that is currently in the Fortune 100. O’Ryan Law Firm has successfully represented many clients whose disability insurance benefits have been unfairly denied or terminated by Aetna.

Short Term Disability Benefits

Aetna’s short term disability coverage pays benefits after a short elimination period (often a week long). Short term disability benefits usually last three to six months. During Aetna’s investigation of the short term disability claim, it is common for Aetna to gather medical records, gather information about the claimant’s job, require statements from treating providers about the claimant’s ability to work and expected duration of disability, and have internal medical consultants review all medical evidence. If the individual is approved for short term disability benefits through the maximum duration of the policy, then they may apply for long term disability benefits.

Long Term Disability Benefits

After an elimination period that is typically the length of the short term disability period, the claimant may apply to Aetna for long term disability benefits. When a claimant receives long term disability insurance through a private employer, their claim is usually governed by the Employee Retirement Income Security Act (“ERISA”).

In addition to information already gathered during the short term disability claim, Aetna will request updated medical records and statements from treating providers, may perform a vocational analysis, and may have internal medical consultants or external medical consultants review the medical evidence. It is very common for long term disability policies to require that the claimant prove disability from their own occupation for the first 24 months of long term disability benefits and then require that the claimant prove disability from any occupation after 24 months of long term disability benefits.

During the long term disability claim, it is more common for Aetna to utilize claim review tactics such as referring the claimant for an Independent Medical Examination (“IME”), contracting private investigators to perform surveillance of the claimant, contracting peer reviewing physicians to review evidence and call the claimant’s doctors, and perform a Transferable Skills Analysis to see if the claimant can return to work in a different job. If a claimant is approved for long term disability benefits, it is likely that Aetna will urge the claimant to apply for Social Security disability benefits. Aetna may even refer the claimant to one of its vendors to represent them in their Social Security disability claim.
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Maintaining or obtaining health insurance coverage is a common problem for those applying for disability benefits. Many Americans receive health insurance coverage through their employer. When a disability forces the employee to stop working, they are at risk of losing their health insurance coverage unless they timely pay the hefty premiums pursuant to the Consolidated Omnibus Budget Reconciliation Act (COBRA). Unfortunately, not having health insurance can be very problematic for those applying for disability benefits.

If the disabled individual is able to afford the premiums for continued health insurance coverage under COBRA, then it is probably in her best interest to pay the monthly premiums and maintain her current health insurance coverage. However, many individuals are unable to afford the monthly premiums without the regular income from a job. When a disabled person cannot make these required payments, they will be forced to find new health insurance coverage or forego health insurance at all.

First of all, applying for disability benefits without health insurance coverage is challenging. Without health insurance coverage, the individual is usually unable to afford the out-of-pocket expenses required for regular medical treatment. The individual may miss out on important testing, medications, and regular examinations. Of course, if the patient is not seeing their doctor, there will be a lack of current medical records to document the patient’s disability. For both long term disability claims and Social Security disability claims, a lack of ongoing medical treatment can make it much more likely that their disability claim will be denied.

Second, the claimant should do everything in his power to obtain health insurance. This includes looking for private health insurance via the federal health insurance marketplace: https://www.healthcare.gov/ If the individual cannot afford private health insurance options, they should investigate whether they are eligible for their state’s Medicaid program. For Indiana residents, information about applying for Medicaid can be found at the following website: http://member.indianamedicaid.com/apply-for-medicaid.aspx. Even if an Indiana resident is not eligible for Medicaid, they may still be eligible for another state program, such as Care Select, Healthy Indiana Plan, or Hoosier Healthwise. If the individual already receives Social Security disability benefits, then they should eventually be eligible for Medicare, although there is a two year wait to qualify for Medicare.
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Sedgwick Claims Management Services (“CMS”) is a third party claims administrator hired by insurance companies and employee benefit plans to manage disability claims. If your employee benefit plan uses Sedgwick CMS as a claims administrator, then Sedgwick CMS is responsible for deciding whether your disability claim is approved or denied. As well as processing and adjudicating disability claims, Sedgwick holds itself out as providing the following services:

The company specializes in workers’ compensation; disability, FMLA, and other employee absence; managed care; general, automobile, and professional liability; warranty and credit card claims services; fraud and investigation; structured settlements; and Medicare compliance solutions (website last visited August 16, 2014).

Sedgwick CMS is headquartered in Memphis, Tennessee and is one of the largest third party administrators in the nation. Many Indiana employers hire Sedgwick CMS to serve as their claims administrator for employee benefits. Employee benefit plans that currently use or previously used Sedgwick CMS include Eli Lilly & Company, AT&T, Comcast, Walgreens, Franciscan Alliance Inc., SPX Corporation, Ascension Health, Hewlett-Packard, PepsiCo Inc., International Paper, UnitedHealth Group, and many others. If employees of these companies apply for short term or long term disability benefits, Sedgwick CMS is responsible for processing the claims and deciding whether benefits should be paid. As a third party administrator, Sedgwick CMS does not actually pay the disability benefits. Rather, the employee benefit plan or insurance company pays disability benefits if Sedgwick CMS approves the claim. Often, the employee benefit plan has little involvement in the disability claims process, if any.

Like disability insurance companies, Sedgwick initially reviews a disability claim by obtaining medical records, requiring the claimant’s treating physician to complete questionnaires, and having in-house staff (nurses, doctors, vocational analysts, claims analysts) review the claimant’s file. If the claim is denied and the claimant appeals, then Sedgwick’s review of the appeal will likely include the use of contracted record reviewing physicians. If the claim is approved, Sedgwick may call or write to the claimant frequently in efforts to obtain more information. Sedgwick may also require the claimant to undergo an “Independent Medical Examination” or “Functional Capacity Evaluation.”
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Cigna, headquartered in Bloomfield, Connecticut, is a global health services organization and its insurance subsidiaries are major providers of medical, dental, disability, life and accident insurance and related products and services, the majority of which are offered through employers and other groups. CIGNA is one of the top health insurers in North America, with medical plans covering nearly 12 million people. Cigna operates in 30 countries, has approximately 40,000 employees and manages around $54 billion in assets.

CIGNA is the parent company of Life Insurance Company of North America. Life Insurance Company of North America (“LINA”) offers group life, accident, and disability insurance to employers. LINA was formed in 1956 by Insurance Company of North America (INA), a CIGNA predecessor company. LINA provides group disability insurance to many employers across Indiana including Toyota, the University of Notre Dame, State Farm, Sony Electronics, Covance and many others. Employees of these companies are provided short and long term disability benefits if they become unable to work due to injury or illness. LINA is responsible for processing the claims and making monthly benefit payments if the claimant proves that they are disabled and unable to return to their own occupation.

During the claims process, LINA will have a Nurse Case Manager review the medical records to determine whether an individual meets the definition of Disabled under the terms of the policy. If necessary, the Nurse Case Manager will escalate the review to a Cigna Medical Director who is an employee of Cigna. The Medical Director will also review the medical records and reports to determine whether the restrictions and limitations listed by the claimant’s treating physician are supported by the medical records. It is not uncommon for the Nurse Case Manager and Cigna Medical Director to disagree with the treating physician and to find that the claimant is able to return to work despite the medical evidence supporting the claim.
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Functional Capacity Evaluations (“FCEs”) are a type of test used to determine the severity of someone’s physical impairments. FCEs are common in disability insurance claims, workers compensation claims, and other contexts where the level of a claimant’s injury or sickness needs to be evaluated.

FCEs are usually administered by a physical therapist or physician who specializes in occupational medicine. Common measurements during an FCE include how much the claimant can lift, how much they can push and pull, how long they can walk and stand, how long they can sit, the ability to reach in all directions, the ability to grasp and manipulate with each hand, the degree to which a claimant can move all joints, the ability to squat and bend, and the ability to stoop and balance. FCEs can vary in duration: some FCEs are very brief – only a couple of hours – and some FCEs are actually performed over the course of two days.

In long term disability insurance cases, many insurance policies allow the insurance company to request that a claimant undergo an FCE at a facility of their choosing. A claimant’s refusal to undergo such testing may give the insurance company grounds to deny disability benefits. Therefore, it is likely that the claimant will have to comply with the insurance company’s request for an FCE. However, a claimant may want to consider the following tips before attending an FCE:
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Based in Boston, Massachusetts, Liberty Mutual employs over 50,000 people in more than 900 locations throughout the world. As of December 31, 2012, Liberty Mutual Insurance had $120.1 billion in consolidated assets, $101.5 billion in consolidated liabilities, and $36.9 billion in annual consolidated revenue. The company, founded in 1912, offers a wide range of insurance products and services, including personal automobile, homeowners, workers compensation, commercial multiple peril, commercial automobile, general liability, global specialty, group disability, fire and surety.

Liberty Mutual Group Benefits department provides mid-sized and large businesses with short- and long-term disability insurance products and group life insurance. Many Indiana employers, such as Dow Chemical and Subaru, have purchased short term disability group coverage and long term disability group coverage through Liberty Mutual. Although, oftentimes Liberty Mutual is only the claims administrator for the short term disability coverage and does not insure the short term disability benefits. By issuing the short term and long term disability policies, Liberty Mutual agrees to pay income replacement benefits to employees who become disabled due to injury or illness.

On their website Liberty Mutual notes that as far as Long-Term Disability:

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.
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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:
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