Helping San Diego’s Disabled Overcome Wrongful Denials of Disability Benefits
Any injury or illness that prevents you from completing the important duties of your occupation may qualify you for individual or group long-term disability benefits. More than 40 million Americans report suffering from disabilities, which accounts for about 12 percent of the population. This means that more than 150,000 residents of San Diego alone suffer from a disabling illness or injury.
If you’re one of the many working-age San Diego residents suffering from a disability, you may qualify for individual or group long-term disability benefits. The majority of San Diego’s major employers, including the city of San Diego and the United States Navy, carry long-term disability insurance for their employees. However, getting coverage isn’t the hard part. The difficult and tricky part is obtaining individual or group long-term disability benefits.
For-profit insurance companies provide and administer the overwhelming majority of individual and group long-term disability insurance policies. Your long-term disability claim eats into your insurance companies’ bottom lines, and they’ll find ways to wrongfully delay, deny, or terminate your disability coverage.
To protect your long-term individual or group long-term disability benefits in San Diego, call the top-rated ERISA attorneys and nationally renowned disability lawyers at DarrasLaw today. We’ve spent more than 60 years litigating and fighting insurance companies to recover individual and group disability benefits. To schedule your completely free San Diego disability policy analysis or free disability claim consultation, contact us today at (800) 458-4577 or online.
The Ins-and-Outs of Long-Term Disability Insurance in San Diego
While every individual or group long-term disability insurance policy is unique, they all provide a type of income replacement insurance if you become disabled and cannot earn a living. How each individual or group long-term policy defines a disability, however, is the key to claiming individual or group long-term disability benefits.
Some individual and group disability policies don’t consider mental health conditions as qualifying even if they prevent you from completing important duties of your occupation. Other individual or group policies only provide coverage if you’re disabled from all work, not just your specific occupation.
All individual or group policies, however, tend to exclude from the definition of disability a self-inflicted or preexisting condition. Furthermore, every individual or group long-term disability policy offers different levels of coverage.
The following types of disability policies provide individual or group long-term disability benefits in the United States:
- Group long-term disability insurance policies – These policies cover a group of qualifying individuals, such as employees or union members. The private insurer will conduct a risk-benefit analysis that weighs the total group premiums against the risk of coverage—that is, the chance they will have to pay substantial disability These policies will typically only cover a percentage of the income from the employee.
- Individual long-term disability insurance policies – You can also purchase an individual long-term disability plan from an agent or broker. This is similar to purchasing private homeowner or car insurance. These plans could provide benefits if you have multiple sources of income and need coverage for your total or partial disability and the benefits are paid tax-free.
- Social Security Disability Insurance (SSDI) – If you pay your taxes, have worked for a sufficient amount of time, and have suffered a total disability, you’re eligible to apply for SSDI. These federal benefits run concurrent to your private individual or group disability plan, so you may claim both. However, using what is called an offset, your group disability insurance company will deduct any Social Security benefits for you and your dependents from what it pays you monthly.
Individual and group long-term disability policies provide additional benefits that Social Security does not. Your individual or group long-term disability insurance policy, for example, may qualify you for partial payments if you return to work part-time.
Long-Term Disability Coverage in San Diego
Most individual and group long-term disability insurers will replace a stated percentage of your lost income depending on your level of coverage. Seems simple enough, right?
Wrong. If you’re entitled to 60 percent of your total salary or hourly wage, it doesn’t mean all that money has to come from your long-term disability insurer.For example, if you make $5,000 per month, you’re covered for as much as $3,000 per month. However, that’s your maximum coverage. If you have the following additional sources of income, your group long-term disability insurance company can use it to offset your payouts:
- Personal injury payments for an accident
- Workers’ compensation benefits for temporary total disability
- Additional income, such as income from a second job
- Social Security Disability Insurance (SSDI) payments
- Pension payments
- Wrongful termination and third-party settlements
- State disability insurance
This means that if you’re entitled to $3,000 a month in group long-term disability insurance benefits, but receive $1,000 a month from SSDI, your individual or group long-term disability insurer will only pay $2,000 per month in coverage.
Individual long-term disability insurance works differently because it protects you personally. If you pay for a private individual long-term disability insurance policy, you can claim a certain percentage of all lost income as a result of your long-term disability, and you receive the benefits tax-free.
The distinction between individual and group long-term disability plans is important because of the laws that apply. A complex set of federal laws called the Employee Retirement Income Security Act (ERISA) generally govern long-term disability insurance policies. While Congress intended ERISA to prevent wrongful denials, it greatly limits your ability to fight wrongful delays, denials, and terminations of group long-term disability benefits. Individual policyholders aren’t generally subject to ERISA’s limitations.
Common Disabling Conditions in San Diego
As mentioned previously, almost any injury or illness can qualify you for individual or group long-term disability benefits. These conditions can include, but are not limited to:
- Tennis elbow
- Neck strains, sprains, and soft-tissue damage
- Carpal and cubital tunnel syndrome
- Bunion surgery
- Lyme disease, Rocky Mountain spotted fever, and other tick-borne illnesses
- Knee and hip injuries and replacement surgeries
- Sciatica, herniated discs, whiplash, and back pain
- Broken bones
- Pregnancy complications
- Migraines, chronic fatigue, and fibromyalgia
- COPD, asthma, and lung conditions
Remember, however, that the sickness or injury must prevent you from performing your occupation’s important duties. This means managed diabetes likely won’t prevent you from working unless you’re continuously dizzy or light-headed. Your treating doctor must also certify that your condition cannot be reasonably managed so as to allow you to work.
Finally, you cannot claim group long-term disability benefits if your employer makes reasonable accommodations for your condition. For example, if you broke your leg and can’t drive to work, you can’t claim group long-term disability benefits if your employer accommodates your cast.
It’s harder to claim individual or group long-term disability benefits for illnesses or injuries that make it more difficult to work instead of actually precluding you from working.
The measure is whether your disabling illness or injury prevents you from performing the material and substantial duties of your occupation. If you’re a traveling salesman and can’t drive due to recent surgery, then you’re prevented from performing an essential occupational function even if you’re otherwise able to sell your product.
An employer cannot accommodate every disabling illness or condition, however. Some injuries and illnesses are so severe you either can’t or are unable to concentrate.
- Renal (kidney) failure – Because your kidneys filter toxins out of your body, when they stop working properly it leads to serious illnesses. This build-up of waste in your body causes weakness, shortness of breath, fatigue, mental confusion, and bloating. You may have to go on dialysis, which can greatly diminish your ability to reliably work. A transplant can cause you to lose work for months as your body adjusts to your new kidney and anti-rejection medications.
- Cancer – While cancer itself can cause disabilities that prevent people from working, many patients suffer more from the side effects of treatments like surgery, chemotherapy, and radiation. Fatigue, bruising, bleeding, infections, confusion, nausea, weight loss, and bowel dysfunction are only a few of the symptoms caused by cancer treatments. If this is the case, the experienced long-term disability attorneys or top-rated group ERISA lawyers at DarrasLaw can help you fight to win the individual or group disability benefits you need to rest, properly heal, and recover.
- Traumatic brain injuries (TBIs) – Common causes of TBIs include car accidents, falls, and high-impact sports. These extremely difficult to treat injuries can directly damage your memory, focus, and problem-solving skills. Many TBI patients also have difficulty functioning in the morning due to extreme migraines and fatigue. Any of these factors can hurt your ability to perform the important duties of your occupation.
- Spinal cord injuries – The nerve fibers that travel down your spinal cord are extremely delicate. Your brain sends signals to the rest of your body through the spine, and any interruption of those signals due to swelling or a traumatic injury can permanently damage your ability to feel or move parts of your body. These problems may result in incontinence or even an inability to breathe.
- Mental health conditions – Whether it’s the traumatic loss of a loved one, depression, anxiety, or dementia, we’ve all experienced mental health disturbances. Certain mental health and emotional conditions are situational or temporary, but others are more serious and lasting. If your mental or emotional illness prevents you from performing the important duties of your occupation, you may qualify for individual or group long-term disability benefits. However, because insurance companies have difficulty with mental health self-reported claims, most individual or group long-term disability insurers limit benefits to a specified time period.
Just because your disabling injury or illness isn’t listed above doesn’t mean you can’t claim individual or group long-term disability benefits. If you are diagnosed with a disabling condition or accident that prevents you from completing the important duties of your occupation, you may qualify for individual or group long-term disability benefits.
Consult a Top-Rated Individual or Group Long-Term Disability Lawyer at the Onset of Your Case
While it’s natural to wait to hire a lawyer until something bad happens—such as a wrongful delay, denial, or termination of individual or group long-term disability benefits—that’s not a good idea.
ERISA, which generally governs group long-term disability plans, actually imposes restrictions on wrongful delay, denial, and termination litigation based on the evidence submitted before denial and after appeal.
Under ERISA, you must timely file an administrative appeal with your long-term group disability insurer after a wrongful delay, denial, or termination of disability benefits. If you don’t, a judge will almost certainly dismiss your otherwise valid claim.
Furthermore, your entire federal ERISA lawsuit is limited to the evidence submitted in your underlying disability claim and your group administrative appeal. This means if you didn’t know to submit witness statements, treating physician and pharmacy records, and relevant legal arguments, you can’t introduce it during litigation. Even if the evidence would make all the difference, you’re probably out of luck.
For this reason, don’t apply for group long-term disability benefits without help. Call a top-rated ERISA group attorney from DarrasLaw as early in the process as possible. We can help you file the most legally sufficient disability claim application and administrative appeal possible. This, in turn, will greatly strengthen your case should you need to file an ERISA federal lawsuit.
If You’re Disabled in San Diego, Call the Experienced Award-Winning Group ERISA Attorneys and Top-Rated Individual Disability Lawyers at DarrasLaw Today
While the prospect of fighting a wrongful delay, denial, or termination of individual or group long-term disability benefits is daunting, a top-rated ERISA lawyer or nationally renowned individual disability attorney at DarrasLaw will know how to do it. In fact, the Darras firms have recovered nearly $1 billion in wrongfully denied insurance benefits.
America’s top-rated long-term disability lawyer, Frank N. Darras, and the lawyers at his firm have more than 100 years of combined litigation and claim experience in the field of disability insurance law. We’ve seen it all and beaten every major disability carrier.
To schedule your completely free disability policy review and free case analysis, call us today at (800) 458-4577 or contact us online.