Find the Answers to Your Pennsylvania Workers’ Compensation and Disability Benefits Questions
Most people navigating the workers’ compensation and disability benefits application processes come to us with questions and confusion. Here, we share some of the questions that we answer most about the disability and workers’ compensation application and appeals processes. If you have a question for us, check out this page to see if we have answered this question for others!
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What is an internal appeal?
An internal appeal occurs entirely within the insurance company. Claims representatives gather medical records and may have them reviewed by physicians or other medical analysts. Claims personnel may call your physicians to ask them questions. Your physicians may receive forms with requests to fill them out.
You should assume that though the law imposes upon the insurance company the obligation to perform a fair and impartial review, they will not do so. Remember, the insurance company will be paying these benefits out of its own pocket, yet they are going to be making a decision on your claim. Furthermore, all the documents gathered by the insurance company will be the entire record in your case if you have to file an appeal of the decision to a court. You will not have the right to testify before a judge or jury if your benefits are covered by federal law. Furthermore, you will not be permitted to put additional records of any kind, including medical records, before the judge who will decide your case. Most galling of all, the decision of the insurance company is entitled to a presumption that it is correct.
What appeal rights do I have if my application for benefits is denied?
Your insurance policy contains a description of your appeal rights. Frequently you have up to 180 days to file an internal appeal of a decision to deny or stop your benefits. If you do not file the appeal within the time period required by the contract, you will lose forever your right to challenge the insurance company's actions.
How do I find out if I'm qualified to receive short term or long term disability benefits?
If your employer provides this type of coverage, you should ask for a copy of the summary plan description, which describes what the insurance company requires you to prove to be entitled to benefits. Although these policies vary widely, in general you are entitled to receive short term or long term disability benefits if you are disabled from performing your regular occupation. If you receive long term disability benefits for two years, however, many policies provide that you are entitled to receive benefits only if you are disabled from all forms of employment considering your age, education, vocational background, and residual physical capabilities.
How can I protect myself if I become disabled?
Though insurance companies have an incentive to pay the least amount of money possible in short term and long term disability benefits, most the time you will not have a problem if your injuries are obvious.
Even where the injuries are obvious, however, you may have problems if you do not receive benefits within a month. Call a lawyer if this happens.
If you are receiving long term disability benefits and the insurance company informs you that they're reviewing your right to receive benefits, you should contact a lawyer immediately. This review process often occurs when you are approaching the period of time in which the definition of disability changes. As noted in answer to an earlier question, after two years, many long term disability policies provide that you have to be disabled from all employment to be entitled to continued benefits. It is at that time that many insurance companies investigate your right to continued benefits.
May I collect Bad Faith damages against a long term disability insurance company that has unfairly denied my claim?
Federal laws are laws of the United States government passed by the United States Congress. In Pennsylvania, state laws are passed by the Pennsylvania State General Assembly.
If you purchase personal disability insurance coverage (not through your employer), your benefits are governed by state law. If you purchase disability coverage through your employer, it is likely that your benefits will be governed by federal law.
Why does it matter? Under federal law, long term and short term disability benefits are administered by your employer, which has the right to purchase disability insurance coverage from an insurance company and can permit the insurance company to make all determinations concerning eligibility. Where this occurs, your employer or the insurance company is both the judge who is supposed to determine whether your claim is valid and the party that has to pay the claim. This is an obvious conflict of interest. Can you imagine going to court after suing someone who injures you in a car accident only to find out that the judge is the person that caused your injuries?
Under Pennsylvania law and the law of many states, however, you have rights you do not have under federal law. Under Pennsylvania law, the insurance company has an obligation to negotiate your claim in good faith. If they exhibit bad faith in the negotiations, you have a potential cause of action against the insurance company for punitive damages in addition to your claim for benefits.
What law governs long term disability insurance (LTD) claims?
If your employer provides long term disability benefits, the benefits are probably paid pursuant to a plan that is governed by the Employee Retirement Income Security Act (ERISA). Although it is possible that disability insurance you purchased through your employer is governed by state law, it is more likely that your coverage is covered by the federal ERISA law. If your claim falls under ERISA, you will not recover bad faith damages. No person pursuing LTD should handle an appeal without a lawyer.
Will a disability insurance company pay me benefits while I have a claim for other benefits pending?
Usually insurance companies will do this, but you will have to re-pay the insurance company if you later receive benefits from another source and your disability policy gives the insurance company the right to take a credit for these other benefits.
May I also collect Social Security Disability or other benefits?
It is likely that your long term or short term disability insurance policy contains a “coordination of benefits” clause that gives the insurance company the right to offset any amounts you receive in connection with your disability.
May I collect both workers’ compensation and long term disability benefits?
If you suffer a work injury and you collect long term or short term disability benefits, the contract covering your disability insurance benefits probably will provide that the insurance company is allowed to reduce your benefits by an amount equal to your workers' compensation benefits.
What are short term and long term disability benefits?
Your employer may provide short term and long term disability insurance benefits. Short term disability benefits cover periods generally from about 9 to 52 weeks. Long term disability benefits begin after you have received the maximum amount of short term disability benefits. The main difference between these benefits and workers' compensation is that your disability does not have to be related to a work injury for you to be entitled to them.