Disability benefits are normally offered by insurance companies to employee’s as group disability and extended health packages via employers in an effort to keep the employer’s workforce loyal, healthy and able to access wage loss benefits and medical/rehabilitative benefits on a timely basis. When an employee is injured or develops an impairment that prevents them from returning to work based on medical advice, the insurance company provides wage loss indemnity at the rates provided for in their insurance policy. Disability benefits are offered on both short-term and long-term basis. Each policy will specify the entitlement criteria, percentage of wage indemnity, exemption clauses, and length of coverage.
Normally, disability insurer’s require an application package to be completed by the injured person and their physician to confirm the injuring mechanism, diagnosis, prognosis and impairments as they relate to the workers job duties, if any. Once the application form has been completed and submitted, the insurer will make a decision to offer benefits, or deny entitlement. The insurance policy will dictate the qualifying language for entitlement to benefits.
Medical evidence is essential to the entitlement of disability benefits. Injured employees are required and expected to report their injuries to their medical doctors immediately and on an ongoing basis. Functional ability forms are required to be submitted to your employer and disability adjuster for ongoing consideration of benefits. Refusal to participate in medical treatment or rehabilitative programs could disentitle benefits. Refusing to report the injury to a medical doctor could weaken the claim for benefits. These requirements are completed with reasonable efforts in the circumstances and degree if impairment.
Time and delay are the first tools utilized by disability insurer’s to drive away potential claims. Many claimants become frustrated with the process and all of the medical appointments, forms and paperwork required. Coupled with delay in decisions by the claims adjusters, many injured people are starved for wages and force themselves back to work when they are not medically cleared to do so.
This is where competent legal counsel is required at the outset. Disability contracts and benefits are contractual obligations. Limitation periods, appeals, commencing civil claims for breach of contract and enforcing benefits is paramount in most instances. This is a specialized area of personal injury law requiring thorough knowledge of contractual obligations. Insurance companies target inexperienced counsel and unrepresented claimants to the detriment of the insured person.
Often, an injured worker may be unionized and have access to short-term and long-term disability benefits. However, the administration of those benefits may fall outside of the normal collective bargaining agreement. This is a unique circumstance where unionized workers have access to private counsel of their choice to advance claims for disability benefits away from and separate from their union representatives. In order to determine whether we can represent a unionized worker in a disability benefit dispute, we require a copy of the collective agreement to review and determine our ability to step in and litigate any benefits denials in the courts (with adverse cost consequences on unreasonable insurer’s), as opposed to grieving a denial through the union process.
If you’ve experienced a long-term disability, call Lemieux Litigation today for fair, dedicated and affordable representation.
We’re on your side.