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DISABILITY BENEFITS DENIED
Disability Benefits is a term that is used to describe a policy of insurance that provides income when an insured is temporarily out of work or permanently disabled.
Insurance is contractual. The insurer, by issuing a policy, is really entering into a contract with the insured defining the
rights of the insured by defining which medical conditions can be temporary and which can be permanent. Accordingly, all "individual or private insurance policies" paid for by the individual must be read carefully as they define illness and injury with different contractual terms and provide different medical standards for disability.
There is also an issue of the "own occupation" provisions in private insurance contracts/policies. A policy can cover you if you are unable to continue in your present specialty such as a surgeon. For example, a bad back injury can put a surgeon out of the operating room and totally disabled under his disability insurance. Or it will cover you for being unable to perform in your own general occupation such as a doctor. You can typically--but not always--be a doctor with a bad back.
To not be able to practice medicine in any fashion requires a more serious injury than a bad back. Some policies are so conservative that they require you to be disabled for purposes of any employment such as in the case of Social Security. In short, every private policy must be read in context for the injury or illness to determine what the insured's rights may be.
Separate from "Private Disability" policies as described above, there are "group" policies generally issued by employers. These are also contractual. However, there is one big difference between a group policy and a private policy: If you have to fight for your right under a private policy you are awarded attorney fees upon prevailing. This is not true in most group policies. Most group policies are governed by Federal Law, specifically the Employee Retirement Income Security Act, which preempts state law and requires Federal law to apply. Federal common law does not provide for attorney fees even if a dispute is won in court by the insured. Obviously, that is a big disadvantage in seeking to enforce your contractual rights under an employer-provided group policy. Taking on big insurance companies can be very expensive.
That is obviously a big difference. If it is a private policy, you have the tools to fight unfair insurance practices as attorney fees (which can be substantial) are paid by the insurance company if you prevail, which is more often than not the result. However, not all groups policies are "ERISA" policies just because they say they are a group policy under ERISA. The mere provision of insurance by an employer, without more, does not constitute an employee benefit plan within the meaning of ERISA. Many other things must be done by the employer to have its health plan quality as an ERISA plan.
Finally, it should be noted that since Disability Insurance is basically a contract, there are often contract provisions providing for specific steps to be taken to assert a claim. Notice must be given within a certain time. Various "administrative appeals" must be taken before you can go to court for justice. During this process, important time requirements may be missed and you can lose valuable rights.
You must see an experienced disability attorney as soon as possible after a doctor tells you that you have an injury or accident that could be considered disabling in the short or long run.
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