Group Disability Claims
Disability insurance plans designed for ADA member dentists , and other group LTD insurance plans , are generally regulated by federal law titled the Employees Retirement Income Securities Act ( ERISA ). Under ERISA , state insurance laws are preempted . To put it bluntly , you are prevented from pursuing state law procedures and remedies to protect your rights .
To appeal a group disability claim denial , you cannot immediately sue the company to enforce your rights . You must first exhaust the insurance company ’ s internal appeals process . Just like it sounds , this appeal is often nothing more than an internal review with the same insurer that denied the claim in the first place .
If the insurer continues to deny the claim , you may then file a lawsuit in federal court . But here is the kicker : at this point , ERISA law prohibits the admission of new evidence into the case . You also have no rights to a jury trial to decide your claim .
Under ERISA , you can only sue for what the insurance carrier should have paid you in the first place . As you might imagine , in a system where the worst that could happen to the insurance company is that they have to pay the original claim and nothing else , the insurance companies are emboldened to deny claims as they see fit .
Know Your Policy ’ s Terms and Definitions reduced if the insurer says you only qualify under the partial disability part of their policy .
Before you ever need to file a disability claim , be proactive .
Do you have an “ Own-Occupation ” policy ? Prevalent in most private disability plans , “ own occ ” coverage is occupationspecific . The definition of disability relates to your specific occupation or sub-specialty rather than the broader definition of “ any occupation .” E . g ., your occupation is defined as “ endodontist ” or “ oral surgeon ” rather than “ dentist ” or “ practicing dentistry .”
Conversely , group LTD policies are often written as “ any occupation ” where it is much harder to qualify for benefits . You must prove you are unable to work in any
job that is reasonably suitable for you based on such things as education , experience and age .
Before you ever need to file a disability claim , be proactive . Get a copy of your disability policy , understand its terms and definitions . With so much at stake , have a plan in place if the day comes when you must file a claim .
The reality is , paying high-dollar insurance premiums for disability coverage is a billion dollar business . The burden to fortify your claim with great attention to the smallest details will be yours .
Marc Whitehead , Esq . is the founding partner of Marc Whitehead & Associates , which he established in 1992 in Houston . His firm specializes in disability law , and he is a frequent lecturer on the topic . Marc earned his undergraduate degree from Texas A & M and his juris doctorate from University of Houston . For more information , please call 713.228.8888 .
The language in your disability policy can be the key to actually getting paid . Terms and provisions used in a policy are never accidental , and are just one more way for insurance adjusters to limit or deny coverage .
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How your policy is written determines how to develop your application for disability . For example , what is your policy definition of total disability compared to partial or residual disability ? Even if you are not totally disabled , by losing the ability to handle routine dental procedures , your income can be drastically
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