Do You Need Representation for Long Term Disability Benefits?
Do you need representation for LTD benefits
While the process described above is relatively straight forward , many claims are denied.
There are three primary reasons why your claim may be denied:
1. You misunderstand the policy language.
2. You are unable to overcome the “hired gun” experts hired by the insurance company to defeat your claim.
3. You are denied by the internal appeal process and need to file a law suit under ERISA.
The policy requires that you appeal the denial in 60 days. Many of my clients believed that the requirement is satisfied by a letter stating that they are dissatisfied with the decision. This kind of “appeal” rarely if ever leads to reversal of the decision. Hiring a lawyer after the second denial is a waste of time as the Court will not accept any material not previously provided to your insurance claim representative and your Court filing is doomed to fail.
Unfortunately, the worst time to mount a fight against the big insurance company is when you are disabled and vulnerable. As you read this article, think how you might become better prepared to deal with this potential problem. read more
Arizona Retirement System Long Term Disability Income Plan
The following is an excerpt of the Long Term disability provided by the Arizona Retirement system to its employees. The full booklet is available at http://www.azasrs.gov/web/pdf/ASRS_Long_Term_Disability_Brochure.pdf
This plan provides you with a monthly benefit designed to partially replace income lost during periods of total disability resulting from a covered injury, sickness or pregnancy.
It is provided as a benefit under your plan with the Arizona State Retirement System (ASRS). The ASRS has contracted with Sedgwick Claim Management Services, Inc (Sedgwick CMS) for
administration of this Long Term Disability (LTD) Income Plan. Sedgwick CMS makes all initial decisions regarding claims submitted under the LTD Plan.
All public officers and employees who are participants in the ASRS and whom a
participating employer employs in the system are eligible. There are exceptions:
A participant who is receiving retirement benefits from ASRS is not eligible for LTD
During the first 30 months of a disability, including a six-month waiting period, you are
considered Totally Disabled if you are under the care of a licensed physician and are unable
to perform all of the essential duties of the job you held when you became disabled.
After you have received benefits for 24 continuous months within a five-year period, you
are considered Totally Disabled if you are under the care of a licensed physician and are
unable to perform any work for compensation or gain for which you are reasonably
qualified by education, training or experience.
The basic monthly benefit is 66 2/3 percent (66 2/3%) of your Monthly Earnings as of the date that you become disabled.
ADJUSTMENT FOR SOCIAL SECURITY BENEFITS
If you receive benefits from any of the following sources they will be directly subtracted from your basic monthly benefit in determining the amount actually payable to you.
Sixty-four percent (64%) of the initial benefits you receive from Social Security Disability
to you and your family, when paid on account of your disability. Except for a member that
becomes disabled on or after July 1, 2008 eighty-five percent (85%) of the initial benefits
you receive from Social Security Disability to you and your family, when paid on account
of your disability. This amount does not include:
The amount of attorney fees approved by Social Security rules and reasonable
documented costs paid to an attorney to secure the Social Security disability
Any cost of living adjustments that are granted after benefits commence under
Eighty-three percent (83%) of the initial retirement benefits you receive from Social
Security, except for a member that becomes disabled on or after July 1, 2008 eighty-five
percent (85%) of the initial retirement benefits you receive from Social Security.
All benefits, including sick pay, retirement benefits, or disability provided by any other
group insurance contract or benefit arrangement which are financed in whole or in part by
your participating employer. This does not include any retirement benefit that is received by
the member pursuant to a state retirement system or plan other than ASRS.
All benefits for disability under any Workers’ Compensation Act, non-occupational
disability benefit law, the maritime doctrine of maintenance, wages, and cure, or similar
Payments for a veteran’s disability to the participant, if the payment is for the same
condition or a condition related to the condition currently causing the total disability and is
due to, or a result of, service in the Armed Forces of the United States.
Half of any salary, wages or commissions or other employment related pay that a
participant receives or is entitled to receive from any gainful employment.
WHAT ABOUT TAXES?
Your LTD income benefit is considered taxable income and is subject to applicable tax laws. If your disability commenced on or after 7/1/95, fifty percent (50%) of the benefit is taxable.
HOW LONG WILL BENEFITS BE PAYABLE?
Benefits are payable following the waiting period, for the remainder of your period of total disability,
except that benefits will not be payable beyond:
The date you are no longer totally disabled;
The date you are no longer under the direct care of a licensed physician.
The date you refuse to undergo a medical examination or refuse to participate in any work
rehabilitation program for which you are reasonably qualified by education, training or
experience that is requested by Sedgwick CMS.
The later of the following:
a. The later of your normal retirement date or the month following sixty months of
payments if disability occurs before sixty-five years of age.
b. The month following attainment of seventy years of age if disability occurs at sixty-five
years of age but before sixty-nine years of age.
c. The month following twelve months of payments if disability occurs at or after sixty nine years of age.
The date you begin to receive retirement benefits under the ASRS.
HOW TO FILE A CLAIM FOR BENEFITS
You should file your claim as soon as it appears that you will be disabled for six consecutive months. If you are not certain how long your disability will last, you should file your claim when you have been off work or working limited duty for three months.
Contact your Human Resources, Benefits, or Payroll Department to obtain the application
packet necessary to file a LTD claim.
Return the disability packet to your Human Resources, Benefits or Payroll Department.
They will submit the claim directly to Sedgwick CMS.
Once Sedgwick CMS has received the claim, it will be processed and you will be sent
written notice of the status of your claim.
If you disagree with the determination made on your claim, you have the right to request a thorough review of the decision.
The procedure is as follows:
Within sixty (60) days after you receive written notice of the initial determination on your
claim, you must file a written request for a review.
Your written request for a review must be mailed to the address below:
Attn: ASRS Claims Manager
P.O. Box 9830
Calabasas, CA 91372-0830