I began this series on understanding your long term disability policy by saying that it’s not as simple as merely paying your premium and filling out the application after you start suffering from problems. Every policy has specific ERISA requirements that you have to meet in order to qualify for benefits, and so far we’ve covered some of the most common provisions.
After detailing the definition of disability in the first part of the series and covering elimination periods, earnings caps, and more in part two, today the focus is going to be on policy limitations and appeals issues.
Understanding Policy Limitations and Appeals Procedures
Mental health benefits. One of the most common uncovered areas is “mental health conditions.” If you have a disability that is caused solely by a mental health issue such as depression, your insurer may limit your benefits to a time defined within the policy, often 12 or 24 months. It’s worth exploring your condition more fully, though, because certain mental health problems like dementia or other brain diseases will still be covered on a long term basis.
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Pre-existing conditions. One of the big changes going forward because of the Affordable Care Act is that insurers have to cover you for problems that you had before signing up with them. However, even last year most insurers included clauses stating that they would not pay for pre-existing conditions and had the ability to look into your medical history if you filed a long term disability claim for something within a set time after becoming insured, such as one year. Because of this long-standing provision, many claimants are still fighting their insurers for past benefits they believe they should receive.
Appealing correctly. Sometimes, even though you know that you should receive long term disability benefits, your insurer will deny your claim. That doesn’t mean you should give up – there’s an appeals process in place for a reason! But you need to make sure you work with an experienced long term disability attorney and follow the appeals procedures closely or you can lose your eligibility if you make a mistake. One common rule is that you have to file your appeal within a set timeline after you’ve been denied, but many policies have others, and most in this country fall under ERISA law, which has its own set of appeals requirements.
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