In most cases, employers often require workers to use all their sick leaves before using other disability options. Short term disability benefits are often used after one’s sick leave has been used. Most plans start paying when an employee has been absent for one week or until the sick leave has expired.

Benefits

Many employers provide short term disability benefits for their employees by paying a portion of their salary during their leave. A typical benefit is between 50-70% of an employee’s salary. Some larger employers, however, pay 100% based on the employee’s length of service before dropping to a lesser percentage. A typical plan usually pays benefits for a maximum period of 13 to 26 weeks.

This benefit is usually computed as a percentage of gross weekly salary without bonuses, commissions or overtime.

In California, for instance, these are the common short-term disability benefits available to employees:

1. State Short Term Disability Coverage – Only five states, including California, provide short term disability benefits to all employees. Some states allow insurance companies to provide the coverage; others insist that all coverage be provided by the state and paid through taxes. Among the five states, California has the broadest mandated plan, which provides payment of 55% of the employee’s gross salary up to a maximum of $728 per week after a one week waiting period for up to 52 weeks. The state’s Department of Labor or Office of Unemployment handles all information regarding this short term benefit.
2. Family & Medical Leave Act (FMLA) – The federal law provides job protections for persons who must take time off for medical reasons. The law applies to all employees who work for a company with 50 or more employees ‘in the same geographical area’. Employees covered under the law may avail these protections if they need to attend to their own medical condition or to care for a spouse, child or parent who is seriously ill.To be eligible, an ordinary employee must have worked for an employer for at least twelve months or at least 1,250 hours in the most recent year. This benefit focuses more on job and benefits protection rather than payment benefits. Moreover, a worker who returns to work after taking an FMLA leave retains his former job position, with the same benefits, pay, working conditions, and seniority level. This benefit is available only for a maximum of twelve weeks per year, which may not have to be taken consecutively, or in increments with periods of work in between.
3. State Disability Leave Statutes – Most states have enacted their own statutes to protect employees’ benefits and their jobs while out on disability. Three states have comprehensive family and medical leave laws that apply to employers of fewer than 50 employees. California has 12 weeks family leave plus 4 months maternity disability leave that may be combined for a total of 28 weeks/year.

Both state and federal short term plans can offer income when you take your temporary leave from work at the same guarantees protection for your job and its entitlements.

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Disability Attorney – Dell and Schaefer Attorneys

ERISA /Group Policies Are Different From
Private Policies In Several Significant Ways.

First, with a private policy if your insurance carrier denies your claim, you usually have the right to file suit and begin to gather your evidence. However, with most group policies you must submit an appeal, within a specified time period, directly to the insurance company prior to filing suit. This requires gathering all of the evidence that would be helpful at trial and submitting it with your letter of appeal. In order to present our client’s case in a light most favorable to the insured, we work very closely with our clients and their treating physicians, to insure that the appeals are submitted with an overwhelming amount of information and detail. A well document appeal is essential in order to have a chance of being successful at an ERISA non-jury trial.

Second, unlike a private policy claim, an ERISA disability insurance case is heard in federal court without a jury. There is usually no testimony by the insured, experts, or physicians. The evidence is limited to the documentation provided during the application stage, documents contained in the Appeal, and previously gathered information by the insurance carrier. We prepare all of our appeals in anticipation that the case may go trial in the event an Appeal is denied.

Third, unlike a private claim at trial you are not attempting to prove that you are in fact disabled. The test is much more stringent. The insured has the burden of showing that given all the evidence submitted by the insured and gathered by the insurance company, there is no reasonable way that the insurance company could have determined that the insured is not disabled.

ERISA provides extremely strict guidelines and deadlines for disabled claimants seeking disability insurance benefits under their group policies. If information is not submitted within these timelines, a claimant may be forever barred from introducing the documentation to prove their disability. Moreover, group disability income policies are drafted with ambiguous and confusing contractual terms. These ambiguities provide insurance companies with multiple reasons for delaying and denying disability income benefits. Furthermore, most policies provide the insurance company with full discretion in deciding whether sufficient information has been provided by claimants prior to approving a claim. Given the complexity of the legal issues involved and the tendency of insurance companies to vigorously defend claim denials, evaluation of any potential legal claim on behalf of an insured should be handled by a law firm experienced in insurance claims.

We are available to provide you with a free consultation and review of your disability policy. Please keep in mind that there are time deadlines with ERISA claims and we must have sufficient time to evaluate your claim and take the appropriate legal actions.

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Chiropractor Placed on Claim Despite a “Any Occupation” Provision

Our client, a chiropractor, suffered from severe bilateral carpal tunnel syndrome, as a result of a traffic accident. Our client applied for disability insurance benefits under the terms of his contract. His disability insurance contract defined total disability for the first 24 months as the inability to perform the substantial and material duties of his occupation as a chiropractor. After 24 months the definition changed to the inability to perform the substantial and material duties of any occupation taking into consideration his education, training, experience, and pre-disability earnings. Earnings were defined as “income from work.”

Our client was paid for the first 24 months, however thereafter his insurance carrier denied further benefits, claiming that our client could engage in several other occupations and was thus, no longer disabled. His insurance carrier asserted that since our client did not withhold Social Security from the profits he obtained from his practice, the money received was deemed “dividends” rather than “income / earnings.” Therefore, the insurance carrier considered his pre-disability earnings as $0, despite the fact that he was earning upwards of $200,000 per year. As such, the insurance carrier argued that if he could engage in any job in which he could earn more than $0 per year, he was not eligible for total disability benefits.

We submitted an appeal to the insurance carrier providing ample medical documentation, a report from a vocational rehabilitation expert, and citing applicable case law. Based on our appeal, our client’s insurance carrier reversed its decision, provided all back benefits owed, including interest, commenced monthly benefits, and paid attorney’s fees and costs.

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Disability Attorney Insurance Disability Benefits Lawyer

When an individual buys a disability income policy from an insurance company, the individual and the insurance company enter into a signed contractual agreement. If an individual is disabled according to the terms of the disability income policy, the carrier must pay the claim. The insurance company’s failure to pay benefits is a breach of contract.

If your claim for disability benefits has either been delayed, denied, or your monthly benefits have been cut-off, our law firm can provide you with multiple options. Most denials of benefits do not require the filing of a lawsuit against the insurance company. In many cases our law firm will open the lines of communication with the insurance company and have a claim re-evaluated. Additionally, we will submit a detailed demand letter, which addresses the medical and legal issues and strengths of your claim, thereby giving the insurance company a last chance to pay benefits prior to the filing of a lawsuit.

Some disability policies require the filing of an appeal before a lawsuit can be filed. We regularly file appeals for individuals and for claimants that have group disability policies that were issued by their employer. In many cases we are able to mediate and meet with the insurance company in order to secure benefits without the need to file a lawsuit. If our investigation of a claim reveals that the insurance company did not have a good faith basis for the denial of our client’s claim, we will file a Civil-Remedy Notice with the appropriate State Department of Insurance and Finance.

The final option is to file a lawsuit against the insurance company for breach of contract in either state of federal court. Our firm has litigated multiple cases against every major disability insurance carrier in the country. We have extensive knowledge and experience regarding any all defenses that the insurance companies will raise in attempt to not pay disability benefits. Furthermore, insurance companies respect our law firm’s abilities and are aware that we are relentless in the pursuit of our client’s claim.

All of our litigation clients are represented on a contingency fee basis, which means we do not charge any attorney fees or cost unless we make a recovery for our clients. Disability income lawsuits are very heavily litigated and require hundreds of hours of time. Due to the complexity, risk and hours involved in litigating a disability claim, we intentionally limit the number of cases we handle and are selective in the cases that we pursue for litigation. Uniformly, in disability cases we realize that our client’s future source of income is at stake, and we are committed to quickly obtaining disability benefits that have been wrongfully denied by an insurance company.

If your claim has been denied, you are waiting for a claim decision, or your monthly benefits have been cut-off, we will provide you with a free consultation and evaluation of your claim for disability benefits.

Source: Dell & Schaefer