Individuals who sustain catastrophic injuries may not be able to perform their job duties. Sometimes, a disabled worker may work with reasonable accommodation. However, in most cases, a disabled worker cannot work even after modifications at the workplace. The long-term disability (LTD) coverage allows a worker to get paid even when not working.
The process of applying for LTD worker compensation benefits is often confusing. In this blog post, you will find out all about making an LTD compensation claim in California.
Defining LTD Worker Compensation Disability
Disability refers to the inability to perform work. A disability can be of two types. Total disability means a worker is unable to perform work duties due to an injury. In contrast, partial disability means a worker is unable to perform at full capacity.
Most LTD policies only cover total disability. But some also cover both total and partial disability.
The main factor that determines if a worker has a total or partial disability is a doctor’s opinion. The opinion of the doctor will influence LTD policies. Your doctor will have to fill a form to give an opinion about the type of injury.
Aside from the doctor’s opinion, the adjuster will also want proof of disability. You have to show medical records, including MRIs, lab results, and clinic notes.
Moreover, you should continue to get treatment in case of ongoing disability. The adjuster will assess this factor to determine the extent of the disability.
In California, you will receive temporary disability benefits from 104 to 204 weeks. There is no such limit for LTD benefits.
Limitations Regarding LTD Disability Coverage
Keep in mind that LTD coverage does not cover all disabilities. You will not get benefits if the disability happened due to a pre-existing condition. A pre-existing condition means you had sought medical treatment before the coverage. Your claim adjuster may deny the claim if the condition is not covered by LTD policies.
Most LTD policies don’t cover disabilities due to drug abuse or attempted suicide. Moreover, disabilities due to an attempted crime or acts of war are not covered.
LTD policies may also cover a disability due to mental problems. The coverage runs usually for only a year. But exceptions to this limitation include diseases such as dementia or schizophrenia.
If you are not happy with the decision of the LTD claim adjuster, you can make an appeal or sue in the local court.
Should You Appeal or Sue If an Adjustor Denies Your Claim
The foremost thing that you need to decide when an adjuster denies your claim is whether to sue or make an appeal.
Many different factors will determine what actions you should take. In some cases making an appeal is the right choice. The reason you should first consider making an appeal is that lawsuits are costly. Court and attorney fees add up to a large amount.
You should appeal if the adjuster made the decision with incomplete information. It may be that the adjuster had only contacted your family physician. You may be seeing a specialist who may think that you are not capable of work. Also, it may be that the adjuster may not know of the results of a diagnostic test. In these cases, you should write an appeal letter providing the required information.
Know that adjusters can reject appeals when they think there is not enough evidence. You will know about the decision about a month after making an appeal.
You may also make another appeal. But in most cases, the result of another appeal is the same. Months later, you will find that you are at the same point where you started. That’s why you should not make more than one appeal.
After your appeal is not accepted, you should proceed to file a lawsuit. Our professional worker compensation attorneys will help you make the right decision.
How ERISA Affects LTD Lawsuit?
Some employers in the US provide LTD coverage as part of the employee benefits plan. The Employee Retirement Income Security Act (ERISA) applies to the benefit plan.
ERISA is a federal rule that aims to offer security for employee disability programs. The rule influences your right to file a lawsuit in the local court. It prevents you from seeking certain damages such as punitive damages. Moreover, you can’t sue for mental anguish due to not receiving the benefits. The most you can get is pending disability benefits from the company. But some courts may also award attorney fees and court costs on top of LTD benefits.
Courts will overrun an appeal under ERISA only if you prove that the decision was capricious. This is tough to proof prove in the court without the help of a worker compensation attorney.
A lot of challenges are present in making the adjuster reverse the decision. One problem is getting the opinion of a doctor who offers an accurate assessment of the injury. Another problem is of contractual obligations of some LTD plans. Our lawyers will tell you what steps you should take to make a successful claim.
CONTACT BERNARD & BERNARD ATTORNEYS, PERSONAL INJURY LAWYERS FOR A SUCCESSFUL LTD WORKER COMPENSATION CLAIM IN CALIFORNIA
The California Insurance Code Section 10350 applies to the LTD disability worker compensation claim. The law gives a three-year limit to bring a case.
For ERISA LTD programs, courts hold the period in the contract to be valid. This may be as short as five months or even less. The period will override any limitations for bringing a case for LTD worker benefits.
State limitations will apply only in the absence of a deadline in the disability contract. So, knowing about the time limit is important. You may miss the opportunity to file a lawsuit if you miss the deadline.
You should contact Bernard & Bernard Attorneys as soon as possible. Our lawyers will assess your case and inform you about the best course of action. Our legal experts will tell you about the right format for submitting court documents. Getting our help will save time and improve the odds of a successful outcome.