- Short-term disability claim litigation
- Long-term disability claim litigation
- Contractual disability income policy litigation
- Bad faith insurance litigation
Although some cases in this area have common themes, litigation is based entirely on the terms of the contract which governs the payment of benefits. It is a must that the client obtains a copy of his or her policy because the specific terms are important and need to be analyzed.
If you have obtained disability insurance coverage through an employer (or you have purchased an employer-endorsed policy), whether the employer is actually paying for the benefit or not, claims are subject to the federal law known as ERISA or the Employee Retirement Income Security Act of 1974. Those cases that are subject to ERISA have mandatory appeal procedures and regulations that must be followed precisely. Failure to properly follow the ERISA procedures and regulations, including the timely filing of an administrative appeal, may result in the loss of the right to file a civil action.
Most disability policies are governed by ERISA. If you have an ERISA case, your employer must provide you with a copy of the policy after receiving a written request. If they don’t, the ERISA law provides that they will face civil penalties of up to $110 per day until they do provide you with the policy. If you have another type of case, contact the insurance company or your local agent to obtain a copy of the policy.
In most cases, you are considered disabled for an initial period if you cannot return to your prior occupation. In most policies, the definition of disability changes after a two-year period, and you are considered disabled only if you cannot engage in any occupation.
If you have been denied contractual disability benefits which were not endorsed by an employer, you may have a cause of action against the insurance company for bad faith based on their conduct in intentionally and wrongfully denying your benefit. However, ERISA-type policies are limited to suit for the payment of back benefits, with interest. It is possible to obtain an attorney-fee award where benefits have been wrongly denied.
Generally, the statute of limitations for disability insurance cases is four years from the initial date of denial of benefits; however, Pennsylvania and federal law permit the insurance carrier to shorten this period of time in the contract. Once again, it is important that you obtain a copy of your contract to determine the precise statute of limitations applicable to your case.
There can be numerous and complex issues in these types of cases, including the interaction with the receipt of personal injury awards, workers’ compensation benefits, and Social Security Disability to name a few. If you are receiving a settlement or benefits, the carrier may be entitled to some portion of your settlement, or entitled to reduce or offset your benefit. Again, every case and every policy have different terms, so it is in your best interest to obtain a copy of your policy and have it reviewed by QuatriniRafferty if you think you have been wrongfully denied benefits. To schedule a consultation with our lawyers at our Greensburg, Pittsburgh, Latrobe, or Altoona office locations, call 888-534-6016 or complete our online form.
For more information, please visit: A Summary: Long-Term And Short-Term Disability.
Westmoreland County — successful commutation of benefits — We recently helped a long-term client of the firm who had used our services in handling prior workers’ compensation and Social Security cases commute a long-term disability claim that was being paid monthly into a lump-sum payment of future benefits. The client suffered from degenerative medical conditions that prevented him from returning to his prior work, and his conditions remained relatively stable. By commuting his benefits, we were able to minimize his risk of a future denial by allowing him to receive payment for future benefits in the form of a lump sum. We used our extensive experience in valuating cases to negotiate a fair and equitable commutation using the net present value of the claim.
Pittsburgh long-term disability case — successful appeal — Cigna (LINA) recently voluntarily overturned its decision to deny our client’s long-term disability after reviewing the appeal letter and documentation submitted by the attorneys at Quatrini Rafferty. The client suffered from severe multiple sclerosis and had been on claim until the claim was reviewed and denied under an any occupation disability standard. After using our approach to build an administrative claims file, which included the use of vocational and medical reports, as well as the use of a client deposition (that the carrier did not attend after we extended an invitation), Cigna overruled itself and reinstated our client’s claim for continued long-term disability benefits.
When our client was denied in her claim for short-term disability, we stepped in to advocate for her in the appeal process. This client had a job working from her home via computer, but the tasks of her job required a great deal of concentration and long hours at the computer. She began to suffer scary symptoms that her doctors were at first not able to explain. She would have episodes when she could not articulate her thoughts. She would not lose consciousness, but would become confused, weak, and exhausted when these events occurred. She would need to sleep after having these feelings. Her doctors suspected that she was having seizures but could not document seizure activity during the times they performed EEG studies. When her short-term disability benefits were denied, the lack of income added to the stress she was facing because of her medical condition. Her treatments included the prescription drug Keppra, a drug with significant side effects, which forced her to turn to other medications as a result. Eventually, she was diagnosed with a partial seizure disorder, and the medication was adjusted so that she could move forward without significant problems. Our office was successful in having the denial of short-term disability overturned so that our client received the insurance payments she was entitled to under the coverage provided by her employer.