Nov 15, 2024 - Disability Insurance, Disability Insurance Appeals by Seltzer & Associates
When people finally get approved to receive benefits through their long-term disability insurance policy, they often breathe a sigh of relief and assume that they are covered for the future. But then, one day, they get a letter announcing that benefits may be terminated. Or even worse, benefit payments simply stop with no warning.
So, when that happens, is the insurance company acting within their legal rights? Can they terminate your benefits? Can you appeal, and if so, how do you do it? As attorneys who focus on helping professionals receive the full benefits they are entitled to from disability insurance providers, the team at Seltzer & Associates gets these questions frequently. The answers depend on a variety of factors, so we need to take a look at the issues involved before we can assess a company’s right to terminate benefits and the client’s best options for appealing the decision. Here are some of the factors that need to be considered.
Understanding the Reason Given for Discontinuing Benefits
If you received a letter announcing that your benefits would be terminated, the letter probably provided a reason. The reason for termination may or may not be stated clearly. It could be buried in the fine print, and the language may include insurance terminology or legal phrases that have a meaning specific to the world of disability insurance. The insurance company might also have linked the reason for termination to a clause in your policy. For instance, they might state that your policy benefits are being discontinued pursuant to Section 93.17b of your policy and leave it to you to figure out what that provision entails.
In order to understand your rights and the options, it is important to understand the reason given for terminating benefits. If you don’t understand the reasoning or you believe there is more happening than what’s stated on the surface, this is a good time to consult an attorney who specializes in disability insurance claims. We know the terms of art used by insurance companies can help you read between the lines to determine what is going on and why.
The Terms of the Policy are Crucial
Although state and federal laws impose some obligations on insurance companies, for the most part, the companies themselves set the terms by which they are required to live. In other words, the terms of the policies that they write and offer to customers form the basis of a contract. The contract that the insurance company created and that you accepted governs their dealings with you. They are required to pay benefits as specified in the contract, but if that contract allows them to terminate benefits for particular reasons, then they are within their rights when they do so—as long as the grounds for termination have been satisfied objectively. Insurance companies are notorious for making decisions based on incomplete evidence and using that evidence to justify a reduction or termination in benefits.
This is another area where a consultation with a disability insurance attorney can be extremely helpful. We live and breathe these policies, so we can cut through the boilerplate language to identify the terms that govern termination in your particular case. We also understand how to analyze the terms based on legal interpretations handed down by the courts.
Reasons Insurance Companies Frequently Terminate Benefits
The terms of your policy might specify that the insurance benefits will be limited in duration when paid for certain conditions, or they might set a time limit for benefits for all conditions. The policy might also specify that benefits will be discontinued if you take certain actions or if specific circumstances occur. Below are some of the reasons we commonly see insurance companies use as grounds for terminating benefits.
No Evidence of Treatment
Many policies require regular medical exams and treatment as a condition of receiving benefits. If you stopped seeing your doctor or receiving a particular type of care, the insurance company will use that as grounds to terminate benefits. In many cases, recipients of insurance benefits who are still receiving treatment fail to submit paperwork demonstrating their treatment, or they file the appropriate evidence, and the insurance company misplaces it or decides they need additional information.
If your insurer inaccurately claims that you have failed to continue treatment or if you had a good reason for missing appointments, a disability insurance attorney can help you show why benefits should be reinstated. Additionally, if the insurance company believes that the medical evidence shows you have recovered sufficiently but you know otherwise, an experienced attorney can help acquire additional expert opinions to show why benefits are still justified in your situation.
Failure to Apply for SSDI
Policies sometimes require a benefit recipient to apply for benefits through the Social Security Disability Insurance (SSDI) program as a condition of receiving benefits. This may be seen as a waste of time because the standards for receiving SSDI benefits are generally very different than the standards used to qualify for benefits under private insurance. Nevertheless, if the condition is indeed part of the policy, then it may be necessary to provide evidence that you have satisfied the SSDI application requirements.
Chronic Condition Limitations
Sometimes, a long-term disability policy will establish a limit on the duration of benefits for chronic conditions that lead to debilitating pain, such as back problems and arthritis. These limits may also apply to chronic conditions that interfere with mobility, such as carpal tunnel syndrome.
Depending on the policy terms, it may be possible to reinstate benefits by undergoing a thorough analysis to demonstrate how the condition still prevents you from working.
Mental Health Limitations
It is unfortunately common for disability insurance policies to limit the amount of time they will pay benefits for debilitating mental health conditions such as anxiety, PTSD, chronic fatigue syndrome, depression, and drug or alcohol addiction. Professionals in demanding careers such as medicine, accounting, and law are particularly vulnerable to these types of conditions, and they impact performance in ways that make it impossible to perform professional functions.
Generally, policy limits generally do not apply to conditions that are more accepted as debilitating such as schizophrenia, bipolar disorder, and dementia. It may be possible to get a change of diagnosis or make other adjustments that allow you to continue to receive benefits.
Evidence from Surveillance
Insurance companies often “spy” on policyholders who are receiving benefits to determine whether they are truly in need of disability benefits. Social media and other online platforms have made it easier for insurers to watch what benefit recipients are up to. However, this can often lead to policy termination based on incomplete or misleading evidence.
For instance, if a friend posts a 15-year-old picture of you waterskiing or rock climbing, the insurer might use that to “prove” that you are not disabled and do not qualify for benefits. If your insurer claims that you are doing something that demonstrates you have the ability to work and should not be receiving benefits, a disability insurance attorney can help you refute their assertions with persuasive medical and occupational evidence.
Talk to Seltzer & Associates to Learn About Options if Your Benefits Have Been Terminated
When you suffer from a condition that prevents you from working and qualifies you to receive benefits under the insurance you’ve paid for, it seems grossly unfair to have your disability payments discontinued. If the decision was made in bad faith or based on inaccurate information, the experienced disability insurance attorneys at Seltzer & Associates know how to fight to get the treatment you deserve. When a termination involves a policy limitation, our reading of your policy may reveal other options available to you.
If your benefits are being terminated or reduced, we invite you to schedule a free consultation to learn how our team may be able to help you continue to receive benefits under your disability insurance policy. Just call 888-699-4222 or contact us online to get started.