Hot Topics in Short-Term Disability and Long-Term Disability, P3

Welcome to Season 4, Episode 23 of Winning Isn't Easy. In this episode, we'll dive into the complicated topic of "Hot Topics in Short-Term Disability and Long-Term Disability, P3." 

Host Nancy L. Cavey, a seasoned attorney with extensive experience in disability claims, discusses hot topics in both Short and Long-Term Disability. While these topics, stories, and anecdotes are important regarding the world of disability, they weren't necessarily long enough for their own dedicated episodes. That is why, today, we've decided to bundle a few together in order to provide insight over a broad spectrum. Today, your host, Nancy L. Cavey, will provide valuable insights into the workings of the disability claims process.

In this episode, we'll cover the following topics:

1 - Does My Disability Insurance Carrier Have to Approve My Long-Term Disability Claim if They Have Approved My Short-Term Disability Claim?

2 - Do You Make Too Much Money to File a Claim for Residual Long-Term Disability Benefits?

3 - Don’t Mess with a Disability Carrier and Fail to Tell Them about Work Activity – A Tale of How One Attorney Destroyed His Case

Whether you're a claimant, or simply seeking valuable insights into the disability claims landscape, this episode provides essential guidance to help you succeed in your journey. Don't miss it.


Resources Mentioned In This Episode:

LINK TO ROBBED OF YOUR PEACE OF MIND: https://caveylaw.com/get-free-reports/get-disability-book/

LINK TO THE DISABILITY INSURANCE CLAIM SURVIVAL GUIDE FOR PROFESSIONALS: https://caveylaw.com/get-free-reports/disability-insurance-claim-survival-guide-professionals/

FREE CONSULT LINK: https://caveylaw.com/contact-us/


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Need help with your Long-Term Disability or ERISA claim? Have questions? Please feel welcome to reach out to use for a FREE consultation. Just mention you listened to our podcast.

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Please remember that the content shared is for informational purposes only, and should not replace personalized legal advice or guidance from qualified professionals.

Transcript

Speaker A [00:00:14]:
 Hey, I'm Nancy Cavey, national ERISA and individual with disability attorney. Welcome to Winning isn't easy before we get started, I have to give you a legal disclaimer. This podcast is not legal advice. The Florida Bar association says I have to say this, so now I've said it. But nothing will ever prevent me from giving you an easy to understand overview of the disability insurance world, the games that carriers play, and what you need to know to get the disability benefits you deserve. So off we go. If you're on disability benefits or you're applying for your disability insurance benefit, I think there's a lot of stuff you need to know. While I do topic specific episodes, I thought reading the recent cases that there were a lot of things to cover that I'm going to call hot topics.
 
 Speaker A [00:01:07]:
 So this episode is hot Topics, and I'm going to talk about three things today. First, does my disability insurance carrier have to approve my long term disability claim if they've approved my short term disability claim? Two, do you make too much money to file a claim for residual long term disability benefits if you've got residual coverage? And number three, don't mess with a disability carrier and fail to tell them about work activity, the tale of how one attorney destroyed his case? Let's take a break for a moment before we get into the hot topics.
 
 Speaker B [00:01:43]:
 Have you been robbed of your peace of mind from your disability insurance carrier? You owe it to yourself to get a copy of robbed of your peace of mind, which provides you with everything, everything you need to know about the long term disability claim process. Request your free copy of the book@kvlaw.com. today.
 
 Speaker A [00:02:03]:
 Welcome back to winning isn't easy. Does my disability insurance carrier have to approve my long term disability claim if they've approved my short term disability claim? Drum roll, please. The answer is no. A policyholder or disability plan participant has the responsibility to provide the disability care with proof that supports your claim. Now, why is this important? It's important because there are different definitions of disability. Short term disability policies or plans generally will have a different definition from the definitions that you find in a long term disability policy or plan. One of the major differences is there's commonly a different definition of disability in a short term disability policy or plan than you'll see in a long term disability plan. So let me give you an example.
 
 Speaker A [00:03:01]:
 It might be that to qualify for long term disability benefits, you have to prove that you're limited from performing the material and substantial duties of your regular occupation due to your sickness or injury. But there might be a completely different definition of disability in the short term disability policy or plan. There are also different definitions of occupations that you may see in a short term disability plan and the long term disability plan or policy. So for short term disability purposes, the definition of occupation might be just how you performed your occupation for your specific employer. So if you're a nurse at Bayfront, the short term disability policy or plan is going to define your occupation as how you do your nursing duties at bayfront. But on the other hand, the definition of occupation in the long term disability policy or plan might be something like this. We look at your occupation as it's normally performed in the national economy instead of how the tasks are performed for a specific employer or at a specific location. So the standard that the disability plan or carrier is going to use when you get to long term disability is not how you do your nursing job at Bayfront and all their maybe little special proclivities or requirements.
 
 Speaker A [00:04:18]:
 It's a national standard of how nursing is performed now. By the way, many times the long term disability policy will refer to something called the Dictionary of Occupational Titles, which is an outdated US Department of Labor book that sort of defines back in the seventies, what the duties were of various occupations. And we all know that many fields have changed significantly and some don't even exist. So that's a big problem, that change in the definition. Now, the other reason that you need to consider is that there are new and different medical records. A disability carrier isn't required to come to the same conclusion as medical records will change over time. So you might develop new medical issues, you might see new doctors, your condition might improve, you might have surgery that allows you to return to work. So the short term disability carrier is going to be looking at one set of records, and the long term disability carrier is going to be looking at another set of records, generally for a different time frame.
 
 Speaker A [00:05:25]:
 So while they look at the records in the short term disability period, they're really concentrating on what's the disabling condition and how is it as of the date you became eligible for long term disability benefits. Now, you need to understand that short and long term disability are not the same animal. What do I mean by that? Short term disability normally will be paid for 13 weeks, 26 weeks, maybe six months, maybe even as long as a year. But after that period of time, you're going to transition into long term disability benefits if you've got, if you've purchased those benefits. And what's crucial, as I said, is there's different definitions of disability, different definitions of occupation, different medical records that they're going to review, and disability carriers are looking for denial reasons in their toolbox. One of those denial reasons is going to be a pre existing condition clause or other limiting clauses that will impact even your eligibility for long term disability benefits or the length of time those long term disability benefits are paid. So it's really crucial, before you stop work and apply for benefits, that you get a copy of the short term disability plan or policy and the long term disability policy or plan and what's called the summary plan description. We want to be reading these documents side by side, the short term disability policy or plan and the summary plan description so we understand what we have to prove in that short term disability claim, and we want to similarly do the same thing with a long term disability policy or plan and the SBD.
 
 Speaker A [00:07:03]:
 So we want to understand what it is we have to prove because they may be cats, but 1 may be a pussycat and one might be a tiger. They're completely different animals. Let's take a break. Welcome back to winning isn't easy do you make too much money to file a claim for residual long term disability benefits? My office recently got a call from a physician who had a long term disability policy. He became disabled, but he was still earning an income working part time. He had never filed a residual disability claim, and he wondered, years after the fact if he could file a claim. It seems that his physician buddies on the golf course, who decided to play disability lawyer instead of practicing medicine, told him he was making too much money to file a claim for his residual long term disability benefits. As a result, he left lots of money in the pockets of the disability carrier.
 
 Speaker A [00:08:37]:
 Now, as time passed and his disability progressed, he had to reduce his hours and stop doing the more lucrative medical procedures that was the bulk of his income. He finally questioned the advice that he had been given by his friends on the golf course, and he was stunned to learn that he was eligible for residual disability benefits. Now, this came as a surprise to him because he had never really read his disability policy or plan. Do you know what's in your wallet? I mean, do you know what's in your disability policy or plan? His doctor buddies didn't know what coverage he had purchased. The buddies probably thought he had a straight total disability policy that only paid benefits if he was unable to work in his occupation as a physician. But what they didn't know, and what he didn't know was that he had a residual disability policy that would pay residual disability benefits based on his lost wages. So, what is a residual disability policy, and how does it pay benefits? Many residual disability policies will start with a determination of what's called before monthly incomes. It's called BME, or there are other abbreviations for it, but, you know, that's the term you're looking for in a disability policy.
 
 Speaker A [00:09:51]:
 Now, the number might be the highest earnings that you've had in the last two years, two years out of the last five years, or even earnings that you had the year before the disability began. Now, you can already hear this involves a lot of math, but let's say that the average number was $200,000 per month. Residual disability benefits typically have what I call a ceiling and a basement, and that's how we calculate benefits. So many disability policies will say that if you earn 80% or more, in this case, $160,000 per month, you aren't entitled to benefits for that month. That's what I call a ceiling. How about the basement? If you earn 20% or less, then you get paid 100% of your benefits, as if you were totally disabled. So 20% in this case is $40,000. If you earn less than $40,000, you would obviously have whatever money you earned, and you would get 100% of your total disability benefits.
 
 Speaker A [00:10:51]:
 Now, in between the basement and the ceiling, benefits are calculated monthly, and what you get paid each month depends on the formula that's found in your disability policy and what you earn too much. Now, you can earn too much one month and not be entitled to residual benefits. In fact, I've seen AIG policies that say if you go one month without being paid residual disability benefits because your earnings are too high, your coverage has gone poof. I mean, gone poof. Okay. So long as your disability is causing the loss of income, you generally are eligible for residual disability benefits. Again, you got to look at your policy. What do we do? Well, we have to gather all the monthly profit and loss statements, the tax returns, and other financial documents, because first we have to calculate this before monthly income number.
 
 Speaker A [00:11:42]:
 That's the number against which, as I've said, each monthly earnings post disability earnings are measured. So then we have to analyze each month's financial records. We create a spreadsheet by month and year so our client could see the money he left on the table. And guess what? He was stunned. He was even more stunned when we filed this residual claim and the carrier paid him the residual disability benefits that were due to him. The lesson is simple. Don't rely on the advice of friends, family, accountants, financial planners or lawyers who don't specialize in ERISA or individual disability law. It takes a skilled and experienced lawyer, an ERISA lawyer, to read a policy, understand the terms, gather the necessary financial documents to calculate the before monthly income, analyze the post disability financial information and medical records for causation, do the calculations and submit a winning claim for residual disability benefits.
 
 Speaker A [00:12:42]:
 So what's in your wallet? Are you missing residual disability benefits? Let's take a break.
 
 Speaker B [00:12:49]:
 Are you a professional with questions about your individual disability policy? You need the disability insurance claim survival guide for professional this book gives you a comprehensive understanding of your disability policy with tips and to dos regarding your disability application that will assist you in submitting a winning disability application. This is one you won't want to miss. For the next 24 hours, we are giving away free copies of the disability insurance claims survival guide for professionals. Order yours today@disabilityclaimsforprofessionals.com. dot.
 
 Speaker A [00:13:46]:
 Welcome back to winning isn't easy. Don't mess with a disability carrier and fail to tell them about work activity, a tale of how one attorney destroyed his case. Now, when a disability insurance carrier puts you on claim or on diary and pays you benefits, they're going to send you monthly, perhaps maybe quarterly, a activity of daily living form that asks questions about your activities, including your work activities. You've got an obligation to tell the truth. I'm sure your mother told you, you have an obligation to tell your truth, to tell the truth. And as your lawyer, I'm going to tell you we have to tell the truth. I don't care how ugly the truth is. The truth is what the truth is.
 
 Speaker A [00:14:29]:
 Now, sometimes clients will say to me, but they'll never know. Oh yeah, they'll find out. And I'm going to tell you the story of how a lawyer by the name of Mister Messing messed up his claim because he thought he could get away with lying. So mister Messing was a former partner in a law firm and he knew the likely consequences of misrepresentation. Now, misrepresentations is a fancy way of saying lying, okay? And he made misrepresentations on his work activity forms as part of the activity of daily living form. He claimed in 1980 he was disabled because of depression. He couldn't handle the stress of being a trial lawyer. Allegedly unimprovident.
 
 Speaker A [00:15:15]:
 Accepted the claim and they paid benefits until 20 1810 years. And guess what they found? He was able to work as a lawyer and terminated his benefits. What he never disclosed was between 1999 and 2013 he worked on 13 cases. The kind of cases he said he couldn't work on. And guess what? He was paid. Now that failure to tell the truth on his activity of daily living form comes back to bite him. Bites him in a couple places. Okay, all Unum had to do, and they will do this, is they did a simple search using pacer and they typed in his name and out spit information about those 13 cases.
 
 Speaker A [00:15:57]:
 And guess what? Ultimately, Unum denies his claim and countersues him for restitution of the disability benefits. Now, they claim that he misrepresented his inability to work and they wanted their money back. Now, fortunately for him, the judge said, look, Unum hasn't been his burden of proof to show that the misrepresentation induced the payment of his benefits. The judge concluded at best, had Unum known about this, it could have investigated the claim. And we can only speculate as to what Unum would have done with this information. What you need to understand is that mesting was, I guess, grateful, if you will, that the disability carrier's claim for restitution was denied by the court. But guess what? The court ruled against him and said you're not entitled to any more disability benefits. Now, this information can be obtained by disability carriers in all sorts of ways.
 
 Speaker A [00:17:00]:
 They can look for conflicts in what you're telling your doctor about what you're doing as compared to what you're putting on the activity of daily living forms. And I assure you, they are going to be doing social media sites. I had a case where my client alleged that he had visual issues and had difficulty using a computer. The disability carrier found out he was a gamer, and guess what? They got video of him gaming. What do you think happened? His claim got denied and ultimately we settled it for a very, very modest sum. Now, in Mister Messing's case, the consequences and my client's case could have been worse. A complaint could be filed with the Department of Insurance alleging fraud, which potentially could result in civil and criminal prosecution. In messing's case, he potentially could lose his legal license.
 
 Speaker A [00:17:56]:
 Based on this misrepresentation. Not only are your benefits at risk, your reputation's at risk, your license to practice law or medicine might be at risk. Why take the risk? Tell the truth. Don't give the disability carrier a reason to deny your claim. They're in the business of denying and terminating benefits, so don't hand it to them on a silver platter. Misrepresentations can result in a claim denial, claim determination, a claim for restitution, a referral to the Department of Insurance for fraud, bar complaints, ethics complaints, you name it, you don't need it. Tell the truth. Got it? I hope you've enjoyed this week's episode of Winning isn't easy.
 
 Speaker A [00:18:38]:
 If you've enjoyed this episode, consider liking our page, leaving a review, or sharing it with your friends or family. And please subscribe to this podcast. That way you're going to be notified every time a new episode drops. I hope you tune in next week for another insightful episode of winning isn't easy, and I hope you've enjoyed our hot topics. Thank you.