What Justifies Being Eligible for Disability Benefits
Do you have a physical or mental condition or even a sickness that prevents you from sustaining regular work on a full-time basis? If so, you may qualify for long-term disability benefits. Understanding the criteria for eligibility is essential for anyone considering filing a claim.
Federal rules, under the Employee Retirement Income Security Act (ERISA), govern claims for employer-sponsored plans. There are significant time-sensitive steps involved, so reaching out to a skilled California disability denial claims attorney immediately can help safeguard your rights. For prompt help, call (818) 356-4747 now.
Key Criteria for Eligibility
Long-Term disability policies have multiple parts to them. There is a short-term portion and a long-term portion that has two separate definitions to it. Most policies define “disability” as an inability to perform the material duties on a full-time basis of your own occupation due to a medically verified condition. However, the exact definitions can vary significantly from one insurance provider to another.
This variance means that a condition deemed disabling under one policy might not meet the criteria under a different policy. The Social Security Administration (SSA) provides a well-recognized framework for understanding disability. According to SSA guidelines, a disability is established when a medical condition is severe enough to prevent engagement in substantial gainful activity and is expected to last at least 12 consecutive months or result in death. However, long-term disability insurance companies do not abide by this rule.
When insurers denies your claim, a California disability denial claims lawyer can review your policy terms and records to help provide guidance and information to help you meet the necessary criteria. We will scrutinize the policy language and compare it with federal standards, and the policy in question, to build a solid case. See the following examples:
Sample 1: Total Inability to Work
Consider an individual whose severe rheumatoid arthritis prevents them from performing any physical tasks required at their job as a warehouse worker. In this scenario, documentation might include:
- Detailed records of joint pain and stiffness from rheumatologists.
- Laboratory test results indicating high levels of inflammation.
- Reports on mobility assessments showing limited physical function. This evidence demonstrates that the condition renders the individual unable to perform the substantial duties of their occupation.
Most insurance companies do not think there is enough. However our office can help explain the information and get additional information to support this claim.
Sample 2: Task-Specific Limitations
Now, take the example of an office worker with carpal tunnel syndrome that makes typing and data entry impossible. Here, the focus shifts to the specific tasks that the job entails. This would apply to your own-occupation definition of your claim. Documentation could include:
- Occupational therapy evaluations highlighting reduced hand dexterity.
- Nerve conduction studies confirming the diagnosis.
- Statements from the treating physician that clearly link the condition to the inability to perform key job functions. This focused evidence can help establish that while the individual may perform some activities, the critical tasks associated with their job are compromised.
Sample 3: Progressive Conditions
For progressive conditions, such as multiple sclerosis (MS), the claim may rest on documented evidence of a deteriorating condition over time. In these cases, effective documentation might include:
- Periodic neurological evaluations indicating worsening symptoms.
- Longitudinal imaging studies (e.g., MRI scans) showing disease progression.
- Detailed treatment plans and medication records outlining changes in the patient’s condition. Such documentation not only proves current disability but also supports the expectation that the condition will worsen.
Accurate objective medical documentation is the cornerstone of any disability claim. Comprehensive test results, detailed treatment plans, and corroborative physician statements serve as critical evidence, both during the initial claim and if an appeal becomes necessary. Additionally, understanding the specific exclusions and limitations within your policy is essential. A thorough review can reveal nuances that might affect your claim, such as pre-existing conditions or policy-specific deadlines for submitting documentation.
Act Now for the Benefits You Deserve
Working through a disability claim can feel daunting, but timely action often makes all the difference. Todd Krauss, APC helps claimants pursue fair treatment, whether through appeals or litigation under ERISA. Secure the support you need to move forward—call (818) 356-4747. Reach out and contact us today.
