Chapter 1: Step Two Proving You Have A Severe Impairment
To qualify for SSDI, your impairment must be established as severe under Social Security rules. Proving a severe impairment is not easy. If SSA finds that your impairment or impairments are severe, then you continue to step three of the Five Step Sequential Evaluation.
Below is information regarding how SSA determines if your impairment is severe enough for you to receive Social Security disability benefits.
How SSA Defines Severity
Severity in impairment occurs when an injury or illnessor combination of injuries or illnessesnotably interferes with your physical or mental ability to perform basic work activities.
Social Security disability benefits are not likely to be awarded if your health issues are considered slight. This is why it is important to have your treating physician specifically describe mental and physical limitations caused by a diagnosed condition.
For example, a doctor should write the patient has difficulty with walking, standing, balancing and muscle control, if that is the case, instead of using general terms like the patient has difficulty performing duties at work.
How SSA Measures Severity
If your impairment is not deemed severe, then SSA will not consider you disabled. SSA does not factor in age, education and work experience. However, it is possible for you to have been disabled for a period of time in the past, even if a severe impairment no longer exists.
Your Employer May Offer Group Long
Your ability to earn income is often your greatest financial asset. But becoming disabled in some way can jeopardize this asset.
Without a stable source of income, your best-laid plans education savings, mortgage payments, retirement goals can fall like dominos. If you cant work due to a health issue, long-term disability insurance can provide a source of income.
Optional And Required Disability Benefits For Your Employees
Disability benefits are employee benefits that guarantee income if an employee cannot work due to illness or an accident. Disability benefits can be optional or mandated by law.
Employers may choose to offer disability benefits to employees who are out of work because of an accident or illness. Most importantly, the illness or injury does not have to be work-related. Long-term and short-term disability policies are the two general categories of optional disability benefits. Employers may also be required to participate in state and federally mandated disability benefit programs.
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Chapter 1: Family Benefits
Veterans benefits may be granted to certain members of an injured veterans family. These benefits may be available to dependents of a living veteran who is unable to support them, or to surviving family members of a deceased veteran.
Benefits for which family members may be eligible include:
- Death compensation
- Accrued benefits, and
- Dependency and Indemnity Compensation .
The dependents and survivors do not have entitlement rights to the disability claims. Any benefits received by family member are based entirely on their qualifying family relationship to the injured or deceased veteran.
Access to these benefits will depend on the circumstances of the veterans service, as well as the veterans relationship to the surviving family members.
Who Qualifies for Family Member Benefits?
Generally, the following family members can qualify for veterans benefits:
Spouse: To qualify, the marriage must be valid and the surviving spouse must be able to show proof of a legal marriage. Veterans benefits may be awarded to a current spouse in instances where a living veteran is unable to provide enough support for a spouse who is in need, as well as a surviving spouse in the unfortunate situation where a veteran has passed away.
Parent: In order for a dependent parent or a surviving parent to qualify for veterans disability benefits, the parent must show that either his or her financial dependency or income eligibility is reliant on the injured veteran.
Chapter 1: File An Erisa Lawsuit
Who Can File a Lawsuit?
Any disability plan beneficiary or participant may file a lawsuit to enforce their rights under the plan or policy. This generally means the disabled individual but in some cases it could be a spouse, an estate or an heir.
Who Is the Lawsuit Against?
A disability insurance lawsuit is usually brought against the Plan or the Plan Fiduciaries, often called the Plan Administrator.
It often happens that the plan administrator is the underwriting insurance company. For this reason, our disability guide often refers to the insurance company when talking about the Plan. More uncommonly, the proper defendant is the claimants employer.
The standard is: Who had the authority under the plan to grant or deny the disability claim?
Where Do You File Your ERISA Lawsuit?
An ERISA lawsuit is filed in one of four locations:
If you are the person bringing the lawsuit, you are the plaintiff. If the insurance company is being sued, it is the defendant.
As plaintiff, your choice of venue is given great deference by the courts. In cases concerning denied benefits, the courts typically decide that the breach of contract occurs where the benefits are to be received. Basically this means you may file your lawsuit where you live or expect your benefit checks to be delivered.
What Remedies Can You Sue For under ERISA?
ERISA law allows you to sue to
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Chapter : The Administrative Law Judge Hearing
The most important level of appeal before the Social Security Administration is what is known as an ALJ Hearing. The hearing is informal and is conducted by an Administrative Law Judge . The hearing takes place in the third step of the appeals process.
The hearings are usually conducted in a small conference room with the judge versus an official-looking courtroom. The hearing is recorded by a person known as a hearing monitor. All testimony is taken under oath, on penalty of perjury.
The hearing generally lasts about an hour to an hour and a half. It is seldom that these hearings take more than two hours.
The Administrative Law Judge
An ALJs job is to issue an independent decision on your Social Security disability case. The decision should not be influenced by the fact your case was initially denied or reconsidered.
Fortunately, more than half of the ALJ decisions nationwide are in favor of the claimant.
Informal Non-Adversarial Hearing
The ALJ hearing is a non-adversarial hearing, which means there is no lawyer on the other side who is going to ask you questions . The hearing is solely for a judge to find out the facts about your disability claim by asking you questions and/or calling other professionals to testify.
Who Comes to the Hearing
Besides these officials and the hearing monitor, no other persons are able to attend the hearing without your permission.
What Questions Will the ALJ Ask?
Chapter : 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
The Cost Of Disability Income Insurance
Disability income insurance has a variety of factors that influence the final premium. Policy premiums generally range between 1% and 3% of the gross income. Insurance underwriters also consider age during the underwriting process. The minimum age for applicants is 18 years, and the maximum age is usually 60. Unlike life insurance, DI rates for women are higher per unit of coverage than those for male applicants.
According to claims data, insurers have historically paid more and higher dollar amount claims for women than men and during an earlier period of life. This may be attributed to pregnancy and childbirth and higher rates of depression and autoimmune disorders. Also, smokers can expect to pay as much as 25% more for the same protection as a non-smoker because of the higher incidence of smoking-related illnesses.
When determining premiums, providers will place applicants into career and income classifications.;The basis of these classifications is on the carriers;claim;experience for these job categories and incomes. The classification with the lowest risk will pay less.
Chapter : Rfc Developing Your Residual Functional Capacity To Prove Your Claim
Being disabled means you suffer from an impairment and symptoms which result in physical and/or mental limitations. Your RFC is the most you can do despite your limitations.
RFC helps to assess the maximum remaining ability you have to do sustained work tasks in an ordinary job setting on a regular and continuing basis. A regular and continuing basis means work done for eight hours a day, for five days a week, or an equivalent schedule.
Your RFC is expressed in terms of the exertional classifications of work. As mentioned above, these classifications are described as sedentary, light, medium, heavy, or very heavy work.
Exertional Activities for LTD Claims
Your RFC must be understood in terms of the seven primary strength, or exertional, activities of work. These consist of three work positions and four worker movements of objects, as follows:
Three work positions:
Definition of Residual Functional Capacity
To determine what you can still do regardless of your impairment, the insurance companys claims analyst should consider all relevant medical and non-medical evidence.
This includes medical records, opinions and assessments by treating doctors, evaluations of the medical evidence by non-examining physicians, as well as your testimony and the testimony of others who have observed you.
The Five RFC Levels
Remember the five exertional RFC levelssedentary, light, medium, heavy, and very heavy.
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Chapter : Is Your Ltd Policy Subject To Exclusions And Limitations
Make sure your policy covers your condition! No policy covers every condition, and those diseases, injuries and impairments that are not covered, or have limited coverage, may carry great weight regarding your claims success.
Get familiar with your policys exclusions and limitations. If the language is unclear, ask the insurance company. We describe common examples below; but read your policy carefully to know exactly what you can expect.
Disabilities Caused by Preexisting Conditions
A pre-existing condition is an illness or injury that began or occurred before you were covered under the policy. Most policies exclude pre-existing conditions, which means you cannot receive benefits if those illnesses or injuries occurred in the past.
Pre-existing exclusions usually come into effect when a person has been eligible for benefits for less than a year Besides the preexisting condition exclusion time period of a year, there is also a look back period, usually the three months prior. This means if you were treated for the claimed condition during the three-months before the effective date of your policy, you are ineligible for benefits.
Basically, if you apply for LTD benefits less than a year after you sign up for the benefit, the insurer will review all your medical and pharmacy records for the entire year plus the look back period, looking for a pre-existing condition.
Mental or Nervous Condition Limitation
How Do I Get Disability Insurance
Many employers offer disability insurance to their employees at no cost or at a discounted group rate, so check with your employer to see if a disability insurance policy is available. If your employer doesnt offer disability insurance, or if you are self-employed, you can also consider looking into an individual disability insurance policy. Even if you do have an employer-sponsored plan available to you, you may wish to purchase additional coverage through an individual policy.
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Chapter 1: Legal Representation For Administrative Appeals
Hiring Legal Counsel to Help with Administrative Appeal
Some claimants try to appeal a denied long term disability claim on their own. A typical example is to prepare a one-paragraph or one-page appeal letter stating something similar to, I appeal your decision. Please reconsider.
If you have read through this disability guide, by now you know that this method is destined to fail. What matters most is the evidence and records you submit with your disability appeal letter.
Skilled legal counsel can make the difference in winning on appeal. To file a successful appeal, a disability attorney will help you prepare all necessary documentation, talk with your doctors, obtain statements from witnesses, consult with qualified vocational experts, and use the latest science and technology to investigate and build the details of your case.
A seasoned attorney will perform many tasks including:
- write the appeal letter to address every one of the insurance companys allegations;
- contact medical and vocational experts to obtain assertive expert opinions;
- send you for a functional capacity exam or other appropriate medical exam;
- obtain updated medical records, and
- investigate the claims file to check for improper procedures or other discrepancies in the insurers handling of the claim.
A few of the legal strategies an attorney will use to put you in the best position to win your appeal are described below.
Load the Administrative Record
Guide To Long Term Disability Insurance Claims
Chapter 1: About Long Term Disability Insurance
The onset of disability can rob you of your ability to work and make a living. Disability insurance policies protect employees and working individuals from the loss of income in the event they become disabled due to illness, injury or other serious impairment.
Insurance companies provide various forms of disability coverage ranging from group workplace benefits to customized, individual benefits, each with varying definitions of disability and levels of coverage.
Examples of some of the largest companies that provide disability insurance include Hartford Life, Unum, CIGNA, MetLife, The Standard, Lincoln Financial, Prudential, Aetna, Dearborn National, Liberty Mutual, Provident Life and Paul Revere Insurance.
Chapter 2: Types of Disability Insurance Policies
Disability policies are separated into two main forms regarding duration of coverage: Short Term and Long Term disability coverage.
Policies are also classified into two main types regarding which laws regulate the policy. These two types include group plans and individual disability policies.
As explained below, the laws governing each are quite different, and will affect your claim in a big way.
Short Term Disability
Long Term Disability
Most long term disability policies have a waiting, or qualifying period. This means that before you can apply for LTD benefits, you first must
Group Disability Plans
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Long Term Care Insurance
Long-Term Care insurance pays for a variety of services for people who are unable to care for themselves due to an injury such as a paralysis from a car accident, a chronic illness such as arthritis, an acute episode such as a stroke, or a cognitive impairment like Alzheimer’s disease. Long term care services may include assistance in a home, adult day care center, an assisted living facility, or nursing home.
New enrollments into LTCi are no longer available as of February 1, 2016.
Employees who had enrolled in LTCi may continue the coverage currently in place. Employees enrolled in this coverage must pay CNA directly for their LTCi premiums.
Chapter : 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.
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Do I Need Both Short Term And Long Term Disability Insurance
As you can probably tell, short term and long term disability insurance policies are designed to work together. Short term disability is intended to cover you immediately following a serious illness or injury, and long term disability insurance is intended to maintain income replacement if your condition keeps you out of work past the end of your short term disability benefit period, even to retirement, depending on your plan. If you have both short term and long term disability policies in place, short term disability will pay you benefits during the waiting period before your long term disability coverage begins, at which point youll transition from one policy to the next to receive benefits. For that reason, it makes sense to have both policies to help ensure an unexpected health problem wont derail your financial confidence for a few months or for several years.