Chapter 17: File A Lawsuit On An Individual Disability Insurance Claim
If you purchased a disability policy privately and you believe your carrier has wrongly denied your claim, you have far more legal recourse than claims subject to ERISA law.
Each insurance litigation case is unique. Some insurance cases can be settled without going to court; others may require a trial to resolve the dispute.
A lawsuit against an insurer for privately purchased LTD insurance is governed by state laws. You are entitled to all procedural rights and remedies available to you in your statejust like you would under your privately purchased homeowners or life insurance policies. You will retain the right to a jury trial and the right to present evidence and cross-examine any witnesses testifying for the insurance company.
In cases where an insurance carrier has denied a claim, most states have multiple remedies available if litigation is necessary. What applies to all state law claims is that you should endeavor to give your insurance company every opportunity to do the right thing and put it in writing.
Many states require that you put your grievances in writing and establish a certain amount of time that must be given for the insurance company to comply. If the insurance company fails to comply with your requests by the statutory deadlines, you probably have many extra contractual remedies available to you that would not be available if your case was ERISA preempted.
Contractual Remedies that May Be Available
- Breach of contract
Chapter 18: Upgrading A Veterans Discharge Status
Can Upgrading a Discharge Make You Eligible for Veterans Benefits?
If you were the recipient of a less than honorable military discharge, then you already know that you are ineligible for veterans benefits. But by upgrading your discharge, you can start receiving the compensation that you are entitled to as a former member of the US armed forces.
All branches of the service have two separate discharge upgrading forums: a Discharge Review Board and a Board for Correction of Military Records for your branch of the armed services. Once the discharge has been changed from less than honorable to general or honorable in one of these two forums, the VA Board must then be utilized to grant veterans benefits.
In general, only veterans who received an honorable discharge or general discharge can be considered eligible for benefits. If you feel that you were issued an incorrect discharge other than honorable, bad conduct, or dishonorable you can fight to overturn that judgment and receive the benefits that you deserve.
With the help of a qualified attorney and veterans advocate, you might also be able to change your bad discharge to a disability separation or simply a retirement. Although you will not receive damages for an incorrectly characterized discharge, you may be eligible to receive back pay benefits if your discharge is deemed illegal or wrongful.
Risks Associated With Upgrading a Discharge to Receive Veterans Benefits
Chapter 14: Step Four Proving You Cant Do Your Past Relevant Work
The SSA will find that you are not disabled if your impairment does not prevent you from being able to perform any of your past relevant work.
Past relevant work is generally defined as full-time work that meets the following criteria:
- You performed the work in the past 15 years
- The work lasted long enough for you to learn to do it
- The work was substantial gainful activity
When the SSA cannot make a decision based on your current work activity and medical facts alone, and it is established that you have severe impairments, RFC plays an important role.
Your Burden to Establish an Inability to Perform Past Relevant Work
You have the initial burden of proving disability by establishing a physical or mental impairment that lasts at least 12 month and prevents you from engaging in any work. You maintain this burden of proof for the first four steps in the five-step sequential evaluation.
At this step SSA does not consider your age, education, employability, or whether past relevant work exists in significant numbers in the national economy.
The fifth step is when the burden shifts to the SSA to show if you can perform other work.
ALJ Considers RFC & Physical and Mental Requirements of Past Work
The ALJ will review your RFC and physical and mental requirements of your past jobs in order to decide whether you can do work you did in the past.
Mental RFC is evaluated according to mental demands of work as described in theCode of Federal Regulations .
Work that is Unavailable
Chapter 15: Special Rules For Combat Veterans
Combat veterans are apt to have a less difficult time getting their condition service-connected than non-combat veterans. VA law makes it much easier for combat veterans to prove that their disability occurred or was aggravated during service. This reduces the chances that the combat vet is denied VA compensation benefits.
This means a combat veteran does not need to show facts to prove that their disability stemmed from a service-related incident. They just have to make a claim that shows to be consistent with the circumstances and conditions in which they were deployed.
In most cases, the combat veterans statement that the disability occurred from a combat incident will be considered as fact. This can only be disputed if someone provides clear and convincing evidence to the contrary.
Why Do Combat Veterans Receive Special Treatment on VA Compensation Claims?
This treatment is not due to favoritism or partiality. The reason combat veterans are treated differently is that during combat, military record-keeping can be very disorganized or faulty. Records are easily destroyed or are incomplete, and in some cases, no records exist at all. Because of this, the VA has chosen to err on the side of the combat veteran with regards to compensation claims.
What Do Combat Veterans Need to Prove to Get VA Compensation Claims Approved?
How Do You Know If an Incident Occurred While Engaged In Combat?
Ways to Corroborate a Veterans Statement about Their Combat Service
Your Claim Start Date
The day you became unable to work due to your disability is the day your disability begins. You may not change the beginning date of your claim or adjust your base period after establishing a valid claim. A valid claim means there are still wages in your base period. If you have any questions about your claim start date, contact DI at 1-800-480-3287 before filing your claim.
Submit your claim following these requirements:
- Wait nine days after you become disabled to file your claim.
- File your claim within 49 days of becoming disabled to avoid losing benefits.
Chapter 15: Insurers Tactics And Claim Denial
Isolating Impairments during Review
Disability claimants frequently have more than one medical disorder. It may be a combination of impairments that causes a person to be disabled. However, during a file review, the insurance carriers hired doctors may focus on each disorder individually to find that the claimant is not disabled based on that one impairment.
It is common for the insurance company to send medical records to several doctors, each with a different specialty. When your medical disorders are separated out, the partial reviews do not reflect the complete picture of your disabling condition. Claimants end up with various expert medical opinions saying they are not disabledbut those experts have not even seen all of the conditions the person is actually dealing with.
Use of Video Surveillance
Insurance companies often hire private investigators to covertly film disabled claimants as they go about their day.
Some insurance companies videotape claimants after they have received benefits for a year or two. The insurance company will allege there are signs revealing that a claimant may be working or be capable of working, so an investigation is in order.
Often, the only type of activity that is filmed is a claimant going to a doctors appointment, going to the pharmacy or passing through a drive-through window. Yet, the surveillance is used to imply that you are able to perform more activity than originally reported, and therefore able to return to work.
Checking The Status Of Your Disability Application
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There is help available while you’re waiting for Social Security or SSI disability payments, but you have to piece it together.
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Applicants who are approved for Social Security disability lose the first five month of benefits.
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Applicants who are approved for Social Security disability lose the first five month of benefits.
Step #2: Va Initial Review Phase
In Step 2 of the VA claim process, a Veteran Service Representative will review your claim.
Itll move to Step 3 if the VA doesnt need any more evidence to support it.
This is unlikely unless you submit a Fully Developed Claim, which is highly recommended.
Do NOT submit a standard claimunless you have to.
This step normally takes around 7-21 business days.
What Could It Mean
There are several different reasons that a transaction could be left as pending.
Abandoned Transactions
Occasionally a customer will put something in their cart, click purchase, go to the payment processor’s page and then choose not to finish the transaction. This will leave the transaction as Pending in your store, but not list any transaction at all in your payment processor’s panel. If left alone, the transaction in your store will change its status to Abandoned. This issue doesn’t have a technical problem, and there’s nothing you need to do about it.
Delayed Completion at the Payment Processor
Occasionally payments can be delayed at the Payment Processor, and it’s not always a problem. For example, a large transaction may be flagged as possible fraud, but be sent through upon review and approval by a human at your payment processor. Another example is that you may set up a rule that says payments in a specific currency should be held for review.
There are a number of reasons payment could be delayed at the payment processor, but you should be able to log into the payment processor’s panel and view the transaction and see the delay.
If you log in and do not see any record of the transaction then it’s almost certainly an abandoned payment as mentioned above.
Technical Problems
The rest of this document discusses how to make your customer happy and find any underlying technical problems.
How Long Does A Va Claim Stay In Preparation For Notification
4/5Preparation for NotificationVAClaim
At this stage, the VA has received enough evidence to make a determination, but has not yet made a recommendation in your case. Preparation for the decision. This means that your VSR has made a decision, but is still preparing a detailed letter outlining the reasons for the decision. Approval of the decision.
Subsequently, question is, how do I know if my VA claim was approved?
- Go to your “My VA” dashboard. You’ll find the link for this dashboard in the top right corner of the page once you’re signed in.
- Scroll down to the “Track Claims” section.
Subsequently, one may also ask, how long does it take to go from preparation for notification to complete?
Congrats!!! The award notification letter is supposed to be completed within 5 days of the rating decision. Once the letter is completed, it is supposed to be approved by a senior VSR within another 5 days.
How long after C&P exam will I get a decision 2020?
It can take as little as three weeks to receive a decision or could take months. It’s impossible to predict. By all means start making appointments for the treatment you need. You can be treated before a claim is even filed or even if it’s denied.
Chapter 2: The Initial Application For Std Benefits
Group Disability Claim:If your coverage is under a group plan through your employer, request the claim forms from your Human Resources department.
Private Disability Claim:If coverage is under your own private plan, also referred to as an Individual Disability Insurance plan, contact your insurance provider for the disability claim forms.
Filing the Short Term Disability Claim
The Application Process
Each insurance provider will have its own specific claim submission information that you must followwhether a claim is filled out and submitted online, by mail on specific forms, or over the telephone.
The claims filing process is basically the same for both short term and long term disability claims, and in many policies the STD claim is just the prerequisite first step to filing the LTD claim.
For detailed information about the filing process, please see:
What to expect on the claim forms:
Generally the paperwork includes :
- Claimants Statement
- Employers Statement
- Attending Physicians Statement
You will need to have your doctor complete the insurance companys Attending Physicians Statement form. In addition, the insurance adjuster will need all medical records and supporting documentation pertaining to your condition. Also to be sent is the list of all medical providers who treat you for the disability.
If your claim is denied, you will generally be notified in writing.
What Does Development Letter Sent Mean On Ebenefits
Development letters are sent in the early stages of your claim. It acknowledges your claim and asks for additional evidence if you have any. The VA is legally required to send this letter to you.
The letter may ask for things that arent applicable to your case, like buddy statements, or it may ask for things youve already submitted, like medical records. The development letter will also contain blank forms. Most likely, you filled out all the required forms already.
The blank forms are only attached if you have additional evidence you want to submit. You do not have to send in everything the VA asks for; you only have to send in anything you havent already submitted.
What Is Paid Family Leave
Paid Family Leave is part of the State Disability Insurance program. PFL replaces some of the income you lose when you miss work to care for a sick relative or bond with a new child, for up to eight weeks in a year. Your benefit amount is calculated the same way as SDI, but there’s a different form to apply for PFL.
Note: Before July 1, 2020, you could only have six weeks of PFL per year.
Chapter 4: Individual Disability Claims Are Regulated By State Insurance Law
Private LTD policies are contracts between you and the insurance provider. Claim disputes under these policies are governed by state contract and bad faith law. If an insurer denies your claim, you can appeal the decision. However, these appeals are often nothing more than an internal review with the same insurer that initially denied the claim.
When an acceptable settlement with an insurance company cannot be reached, bad faith insurance claim litigation becomes necessary. Litigation of private policies are held in state or federal court. The burden of proof is the same as a civil trial. You are allowed a jury trial, and may fully engage in evidence and discovery.
State Protections Available
Depending on the state, the protections and damages that are available to you in a dispute over a private disability claim include:
- Emotional distress
How Do I Stay In The Sdi Program How Often Do I Have To Reapply
You do not have to reapply. However, you must tell SDI immediately if you:
- Go back to work part time or full time
- Recover from your disability, or
- Get any other type of income.
You must also imemdiately report the death of a person getting SDI payments.
At certain times SDI asks you to “certify” that you still qualify for benefits, and if you do not do this your benefits stop. If you are getting automatic payments, you are asked to certify after 10 weeks of getting benefits. If you are not getting automatic payments, you have to fill out a certification form every two weeks.
Once you are on SDI, as long as you are still unable to work because of your disability your benefit payments will continue up until the “return to work” date your medical provider listed on your application. If your disability lasts past that date, you and your medical provider must ask to extend your benefit period. SDI benefits replace up to 52 weeks of lost income, but if you get a partial benefit you might get payments for longer.
Chapter 4: Getting Legal Representation
Initially, claimants are not skeptical of the insurance industry or the disability insurance process. Once their claim is denied, they are at a loss about what to do to get their badly needed insurance coverage.
When it comes to filing a successful appeal, experienced legal counsel is in order. A disability insurance lawyer can take the burden of proof off your shoulders, develop your case properly and apply the law to your benefit, and provide all of the necessary evidence to effectively appeal a wrongly denied insurance claim.
Do You Have Enough Work Credits For Ssd Benefits
You need to make sure that your application accurately shows that you have worked long enough to qualify for SSD benefits. In other words, you need to show you are insured.
This is determined by the number of work credits you have earned. Work credits are based on your earnings. For instance, in 2013, you earned one work credit for every $1,160 you earned. The most work credits you can earn in a single year are four. Your application must show that you pass two different types of earnings tests: Recent work test and duration of work test. The number of work credits you need to pass these tests will depend on how old you were when you became disabled.
Can I Receive Benefits From Both Unemployment Compensation And Ssd Or Ssi
If you receive unemployment compensation while your claim for SSD or SSI benefits is pending, and your claim is approved, your retroactive SSD or SSI benefits will be reduced for the period of time you were collecting unemployment compensation. Typically, unemployment means that you’re capable of working â you just can’t find a job. In order to be successful in your claim to receive SSD or SSI benefits, you must have a disability or condition that prevents you from working at all and that you are not currently seeking employment. There may be exceptions, and you should contact the Social Security Administration to learn if you’re eligible to apply for SSD or SSI benefits.
Division Of Disability Benefits
The Ohio OOD Division of Disability Determination , in agreement with the Social Security Administration , determines medical eligibility for Ohioans who apply for Social Security disability benefits. Benefits include:
- Social Security Disability Insurance pays benefits to an individual and certain family members if the individual is “insured” ;
- Supplemental Security Income pays benefits based on financial need.
Disability, under the SSA, is based on an individuals inability to work. SSA uses the same definition for both benefit types. Unlike workers’ compensation or veterans benefits, SSA has no partial disability category. DDD is a federally regulated division of OOD. It receives 100 percent of its funding from SSA.
Assist someone filing for Social Security disability benefits.
Set Up A Complimentary Consultation Today
Waiting to hear back from the SSA with a decision about your disability claim can be daunting. An experienced Phoenix Social Security Disability lawyer at Dayes Law Firm is ready to communicate with your claims examiner and keep you informed about the status of your disability claim. We could also review your situation for free in a consultation to see if we may be able to help you with an appeal.
There is no upfront cost to use our services. We only receive payment at the end of the claims process if you receive the disability benefits you need. Our firm is available anytime, 24/7, to take your call.
Gives us a call at 1-800-503-2000 to learn more.
Chapter 19: Get Help From An Accredited Va Attorney Claims Agent Or Representative
Filing a claim for veterans disability benefits should be a straightforward task that is met with respect and processed with urgency. Yet for the thousands of veterans in dire need of disability compensation, the process is burdened by unforgivable delays and denials.
A veteran may wait 4 months to 2 years to receive a decision of benefits. If the claim is denied, a disabled vet can spend years more fighting and waiting for benefits. The road to winning VA compensation claims cases can be immensely improved with the help of a qualified representative.
Who Can Assist a Veteran with a VA Claim for Benefits?
Federal law states that the only individuals with the authority to assist a veteran in the preparation, presentation, and prosecution of a claim for VA benefits are those who are accredited by VA as an attorney, agent, or representative of a VA-recognized veterans service organization.
Accredited by the VA means a person has gone through the VAs official training process and is recognized by the U.S. Department of Veterans Affairs as being capable of assisting claimants with their affairs before VA. Accreditation is required to ensure disabled veterans who seek help are receiving efficient and competent representation. The VA lawyer or agent must also comply with the power-of-attorney requirements and the fee agreement requirements as set forth by law.
How Can I Find an Accredited VA Attorney, Agent or Representative?
How Often To Check Your Claim’s Status
Generally, you may want to check the status of your pending disability claim at least once a month. There are certain situations when you may want to check more often, on a regular basis. If you recently submitted an application, we recommend checking within two weeks to make sure it was well received. If you are waiting back for a decision that is overdue, it is important that you check every couple of days.
The SSA should reach out if additional information or medical evidence is needed to process your claim. However, in some rare cases, a decision may not be sent out. Mistakes and mix ups could potentially happen. Missing documentation could stall your claim, paperwork could get lost or misplaced, mail may not reach you in time or get lost, or the SSA may fail to notify that a claim has been denied.
What Are The Medical Eligibility Requirements For Sdi
SDI gives cash payments to employees who are unable to work because of a non-work-related disability, and SDI defines a disability as “… an illness or injury, either physical or mental, which prevents you from performing your regular and customary work.” The definition also includes elective surgery, pregnancy, childbirth, or other related medical conditions. Your medical provider has to certify that your condition meets this definition.
To get Paid Family Leave because you are caring for a sick relative, the relative has to have a mental or physical condition that requires at-home care or in-patient care in a hosptial, hospice, or residential medical facility, with continuing treatment by a doctor or other health care provider.
What The Report Found
OIG analyzed a total of 116,000 deferrals issued between February and April of 2018. Again, unwarranted deferrals refer to when part or all of the deferral was not necessary and claims processing could have continued without rework. Within the 3-month review period, 23,200 out of 116,000 deferrals were unwarranted. OIG found that unwarranted deferrals could result in needless examination costs, delayed processing, unnecessary rework, and improper guidance to claims processors. Specifically, an estimated 7,000 unwarranted deferrals resulted in avoidable medical examinations.
Based on the rates at the time of the review, the OIG team estimated that VBA could spend at least $8.8 million on unnecessary medical examinations taken over the next five years if corrective actions are not taken. Furthermore, of the 23,200 unwarranted deferrals, 16,200 were delayed. Delays averaged 43 days with the longest delay being 232 days.
Ultimately, OIG concluded that VBA staff need to improve accuracy when creating deferrals in order to minimize unnecessary medical examinations, claims processing delays, incorrect instructions provided to claims processors, and unreliable tracking data used to train staff.