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Get Your Disability Claim, Long Term Care Claim or Health Insurance Appeal Off to the Right Start

A lawyer consultation may be all that is needed to answer your questions or to obtain guidance about what steps you should take to best preserve your rights.  Our attorneys can review your employee benefit plan or insurance policy, consider the information you provide about your disability, illness, or medical condition, and provide information and advice based on their familiarity with the law and years of experience handling disability, long term care, home health care, and health insurance claims and appeals.

For example, you may have recently been diagnosed with a chronic, progressive disease, and have questions about the benefits available to you under your employer’s health, life, or disability insurance plans.  Or, you may be considering a change of jobs, and have questions about how your pre-existing illness will affect your rights with regard to coverage and benefits under your new employer’s insurance plans.  Will you have to be on the job a certain amount of time before you are eligible for health insurance, or to make a claim for disability benefits?  How sick must you be to qualify for disability benefits, and how long will it take to get approval of your claim?  Are there steps you can take to maximize the probability that your claim will be approved.

Or, you may have been struggling with a chronic, progressive disease for a number of years, and now feel that your illness is having a negative effect on your work performance.  You may have questions about the timing of your claim (e.g., what start date should you choose), and whether to plan your departure (by announcing that you are retiring or resigning) or to leave abruptly. This blog post, Will My Long-Term Disability Coverage End if my Employment is Terminated While I’m Out on Disability?, addresses some of the complexities that may arise from such seemingly straightforward decisions as selecting your disability “onset” date.

Perhaps there are rumors of company layoffs and you are concerned that your decreased performance puts you at risk of being selected for termination, or perhaps you have already been told you’ll be fired and offered a severance package.  This can be an extremely important moment to assess your rights, as you may be entitled to claim short or long term disability benefits.  The timing of such a claim can be critical.  Accepting a severance package may preclude a disability claim, although it is sometimes possible to negotiate a severance package that allows the simultaneous filing of a disability claim.  The language of any severance-related general release must be carefully examined to ensure that you do not inadvertently release your right to pursue ERISA health insurance, life insurance and disability benefits.  This blog post, Long-term Disability, Lay-Offs, Reductions-in-Force and Severance Packages, addresses some of the issues that may arise when an employee seeks to file a disability claim, in the context of a lay-off, reduction-in-force, and/or when a severance package has been offered.

Perhaps your spouse or dependent child is in the hospital, after an accident or emergency illness, and the treating physician wants to discharge your family member to a nursing home, rehabilitation facility, or at-home private-duty nursing care.  Or maybe your doctor has recommended a surgical procedure or medical treatment, but warned you that your insurance company may give you trouble or refuse to approve it.  Will your insurance provide coverage for these medical services?  If so, at what benefit level and for how long?  What must you or your doctor do to get the medical service or procedures pre-authorized and covered?

Perhaps you or a family member have suffered a serious accident or debilitating illness, and you need the assistance of a home health aide or nurse so that you can safely shower or bathe, get into or out of bed, use the toilet, or dress yourself. Will your long term care insurance provide coverage for a nurse, home health aide, of family member to provide this assistance? What level of disability is required? What if the reason for needing assistance isn’t because of a physical disability, but because of deteriorating cognitive function (due to Alzheimer’s or other forms of dementia)?

Maybe you have a been receiving disability benefits for several years, without question, and suddenly your insurance company is asking more questions than usual, has requested that you be interviewed in your home by a claim representative, is making aggressive demands for records or physician statements from your treating doctors, is demanding that you undergo a functional capacity evaluation, also known as an FCE, neuro-cognitive testing, or an independent medical examination, also known as an IME.  Are you required to comply with these demands?  Do these demands mean that your insurance company is looking for a way to terminate your disability benefits and, if so, are there steps you can take to protect your rights and ensure that your claim is handled in a fair and objective manner?

After practicing for many years as a specialty physician and paying for an elite own occupation disability income policy, you may have questions about whether your inability to perform certain highly skilled and well-compensated procedures (even though you are still able to conduct routine office visits) is enough to qualify for disability benefits under your plan.  Must you stop work altogether, or will your disability insurance provide partial disability or rehabilitative employment benefits if you continue to see patients in the office and perform minor procedures?  Will your business overhead expense policy compensate you for hiring another physician to assist you with your practice or to perform the procedures you are no longer able to do?

By reviewing your insurance policies and plan booklets, we can answer these questions.  We can advise you how courts interpret certain plan provisions, or recommend the sorts of medical information that may be helpful to get your claim approved.  If you are having problems obtaining copies of your insurance policy or plan booklets, we can assist you in making a formal request.  In these kinds of circumstances, we can sit down with you, go over the insurance plans, and discuss the facts of your case.  A single consultation may be all that is needed to provide you with helpful information and recommendations that will get your claim or appeal off to the best possible start.

TELEPHONE:  212-406-9606

Mark Scherzer Law :: ERISA and Insurance Lawyers :: Health, Life and Disability Claim Consultations 
New York Attorneys (including New York City, Hudson Valley, Long Island, Capital-Saratoga, the Catskills and Finger Lakes

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  • New York Office
    110 Lasher Avenue
    Germantown, New York 12526
    Phone: 212-406-9606
    Fax: 212-964-6903
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Monday – Friday | 9:30 a.m. – 6:00 p.m.