Pursuant to federal law if an employer provided disability plan denies a claim for benefits, either short term or long term, the plan or claim administrator must provide the participant or beneficiary with a written explanation of the denial, framed in language that the participant or beneficiary can understand. The plan must also provide for an opportunity for a full and fair review of the denial by an entity designated by the plan. Those making disability claims are required to “exhaust administrative remedies” by completing the denial review or appeal process prior to filing suit to obtain benefits.

It is critical to present all evidence to support a claim for disability benefits during the appeal process. Court rulings have prohibited consideration of evidence in support of disability after a suit has been filed that was not presented to the review entity designated by the plan.

A typical long term disability plan has two definitions of “disability” to determine eligibility. The first period of coverage, normally 24 months, is under a “regular occupation” definition. The material duties of the regular occupation of the employee are reviewed to determine whether the claimant is unable to perform those duties. Once the “regular occupation” period has ended the disabled employee must meet the “any occupation” standard which looks at the capability of the claimant’s age, education, training, and experience. The physical capacity to perform a different job; sufficient training to be qualified to perform the work of a different occupation; and the actual availability of other jobs are factors that are considered.

Common to all long term plans are offset provisions which deduct from the monthly benefit other disability income benefits such as social security disability; and termination of benefits at the age of 65.

If you need representation to make a claim for disability benefits, whether you need assistance with the review or appeal of a denial or making a formal claim in federal court please call Bogin, Munns & Munns at 407-578-1334.