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How Do I Qualify for Disability Insurance Benefits? - YouTube
Channel: Dell Disability Law
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[Music]
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hi i'm greg dell here with steven jessup
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and cesar gavidia and the question of
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the day today is do i qualify for
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disability benefits and specifically
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disability insurance benefits because
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we we're a law firm that only handles
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long-term and short-term disability
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insurance claims yet there's maybe 150
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000
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disability insurance claims and over 3
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million claims a year for social
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security disability so there's a a big
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difference between those two so for our
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video we're focusing on the disability
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insurance benefits and this question is
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probably one of the most popular ones
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that comes up in a google search and
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most employers or most employees who are
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at work are often thinking you know i
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have a condition
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might be difficult for me to work but if
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my employer provides me with a policy
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do i qualify what does it take so
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cesar what's the starting point for
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someone to figure out if they qualify
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for benefits
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well the obvious thing is that they have
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to have some sort of sickness or injury
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that's creating some sort of problem for
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them
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that is creating some sort of limitation
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for them that's preventing them from
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really effectively and adequately
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performing their occupation
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okay and that's kind of like the
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threshold
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from there in many in most cases what a
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disability insurer is going to want to
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see is
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support within the medical records
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within your doctor's records
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supporting that those limitations lining
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up with an opinion from your doctor that
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you're not able to work or that you
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shouldn't work or that you you need to
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take leave from work
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okay well i want to back it up a step
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because medical support is is essential
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but steve
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how important from the beginning people
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call they don't even have a policy
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i mean what is the policy and then how
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important is it to understand that
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policy well the policy first in
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qualification too one of the big things
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especially on employer-provided policies
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how long have you been covered
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is there going to be concern for
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pre-existing condition you may have all
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the medical in the world to support you
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can't work but if you don't qualify
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beyond a pre-existing condition problem
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you're never going to you know see those
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benefits um and what did you sign up for
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i mean i'm sure we've all taken calls
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where they signed up for short term but
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never bothered to enroll in the
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long-term disability policy things like
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that so you know having copies of it and
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a lot of times people are concerned well
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if i ask my company they're is it going
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to tip them off and and i usually tell
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people if you want to get a copy of the
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policy the best way to ask say tell the
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hr that you need a copy of any and all
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insurance policies you have because a
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lot of times the summary plan
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descriptions will send you everything
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your life insurance your dental your
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vision you can get it that way so you at
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least have an understanding you know
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from a general sense as to what this is
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going to cover because you could qualify
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right medically you could have all this
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stuff that qualifies you but the reality
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of the disability claim is you may still
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never be approved so there's there's a
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nuance and there's an art to this idea
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of the diagnosis translating into a
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disability like caesar is saying and
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then still having to deal with an
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insurance company that's incentivized
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not to pay your claim
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um so the policy is the foundation and
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then built on with the medicals and all
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that stuff but it's such a hard question
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to be able to answer do you qualify
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if you have a doctor who's willing to
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support you you have coverage under
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policy you can't work uh it's your only
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option then i say you you have to give
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it a go
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but it doesn't necessarily mean that
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you're ever going to see a payment from
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the insurance company
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caesar in terms of the employer
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providing the policy because most people
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who call and say do they qualify they
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haven't even obtained their policy and
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and one of the things that we always do
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is we tell a claimant when they reach
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out to us please send us a copy of your
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policy we'll provide you with a
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complimentary review of that policy and
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then we'll discuss your options
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why is it so important for you to have
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that policy are they
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they're not all the same correct no
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they're not all the same there's
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certainly similarities amongst
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group disability plans
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um but
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like steve was was explaining if you
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know
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even pre-existing conditions which
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appear in almost every single group
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disability plan plan can
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can be different they could they could
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be different in terms of how long that
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pre-existing condition period is for how
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long um perhaps that that
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that period for which you have to file
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disability that you file disability will
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be considered a pre-existing condition
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how long that period's for so
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and aside from that
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different types of limitations mental
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nervous limitations there's even now
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neuromuscular skeletal limitations in
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disability policies that that's becoming
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more and more common among disability
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insurers so
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before before anything you have to have
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a copy of your policy so that you have
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you understand
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what the terms and conditions are that
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must be met before you can begin
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receiving benefits so steve we're
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talking about this pre-existing
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condition and some people we're talking
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like industry lingo and policy language
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what is it real quick existing condition
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i think most people have a general
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concept from health insurance and they
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also think oh you know with with the
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affordable healthcare act obamacare that
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pre-existing conditions got wiped out
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well health care but not in disability
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so the the standard language i would say
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you most commonly see is if you've been
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covered under the policy for less than a
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year so especially some people i've been
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working for my company for a year but if
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they had to wait 90 days before the
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coverage came in that's when it starts
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so typically if your
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file within one year of coverage they
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will look uh back to like usually three
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to six months prior to the start date of
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coverage to see if you had treatment
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for any medical condition that you are
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now claiming is disabling you and if you
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had they have a route to be able to
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argue it's a pre-existing condition and
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they don't have to pay it and on the
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long-term disability policies you'll see
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it in short term not not nearly
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obviously as often as long term but the
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the reason why it's contained in so many
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long-term policies it's a way to avoid
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someone getting a job just to try to
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file for a disability right away so
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there is that period and there's been
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times with clients and they'll call us
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and we we have to advise them you have
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to try to wait you have to wait to be on
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this date or you won't have any grounds
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whatsoever
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so the policy is the rule book you know
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this is how things are going to work it
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gives you a road map if you don't have
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that you know you can file a claim and
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you may eventually get to a result
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somewhere but it's going to be a lot
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harder and it's going to be a lot more
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confusing than if you know what to
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expect getting into it but even if a
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person has a condition that they had
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before they started working if the
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policy says you have to work at least 12
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months and then on 12 month and one day
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they then make their claim would they be
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okay even though they had approved that
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yeah so you can have a pre-existing
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condition you have bad back for years
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and years and years right but if you're
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able to work for that full 12 months is
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required before you filed that
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pre-existing is not going to go granted
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the insurance company may still try to
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they'll still on the back and do a
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review to see but yeah there shouldn't
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be you know an issue there all right
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caesar you get through and we review a
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policy and we say yeah you're gonna you
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know no pre-existing and it looks like
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you have a decent policy and here's what
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needs to happen
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you started before earlier medical
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support
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why is that the foundation of the claim
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why is the why is it so important well
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the insurance companies looking at
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looking at that your medical support as
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the evidence which supports
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your claim of disability
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certainly it's it's
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it wouldn't be reasonable to expect an
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insurance company just to take you on
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your word that you're disabled there's
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got to be a foundation there's got to be
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evidence to back it up and that's why
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your medical records are important
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your medical history is important
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and for the insurance company to have
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that in fact that's that's
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written into the proof of loss
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requirements in these disability
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policies they have to have medical
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records to support your basis uh in
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claim for disability all right so often
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a claimant calls and and they're looking
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to qualify and i'll always say does your
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doctor support you
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and
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half of them will be like well
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i think so
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how important is it to number one
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have that conversation with your doctor
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about whether or not they support the
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claim and number two
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when do you have that conversation
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before you file the claim
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or i should say before you stop working
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or after you stop working
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i don't know which one you want i i
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don't think that it's gonna really help
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you much to have that support built up
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after you've stopped stopped working
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already um
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because i think the the basis and kind
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of that that event that that occurs
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to kind of
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push you into
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that claim of disability has to be your
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doctor having done an examination of you
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has to be a documentation of of your
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symptoms of the the problems you're
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having and an opinion from your doctor
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saying look you shouldn't continue doing
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what what it is that you're doing that
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either you're not doing effectively
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enough or perhaps even maybe aggravating
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your your condition
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but what about the person see if who
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calls you and they go look my back's
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been bothering me for two years and i've
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been working through the condition that
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that's very common and now they're like
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it's so bad that i'm finally going to
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the doctor is
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one doctor visit enough with someone
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who's chronic and now they want to file
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i mean
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how when when is that person supposed to
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file and well there's no hard fast rule
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but if you have very thin paperwork it's
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not going to be taken seriously by the
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insurance company unless there's a
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catastrophic injury right you're getting
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an accident right then there's that but
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chronically speaking they're always
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going to come back you were able to work
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with this you didn't seek medical
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treatment so it must not have been that
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bad so they'll use that against you you
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know then going back to with the doctor
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support doctor's going to have to follow
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an attending physician statement you
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know as part of the claim um and what
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what is that that's the form basically
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of your doctor discussing what the
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medical problem is your restrictions and
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limitations why you can't work
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um and you'll see plenty of denials that
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come where the doctors don't want to get
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involved right they won't fill out forms
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that's another question asked if the
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doctor is going to assist because
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doctors are no duty to fill out these
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forms for you and there's a lot of times
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they don't want to you know get involved
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in dealing with an insurance company and
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if they don't fill it out or you know
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god forbid they check the wrong box or
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i've seen plain as day where you know
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they'll put i've provided no
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restrictions or limitations for this
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person's return to work i i don't have
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any i'm not i didn't take them out of
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work on this and under this idea if you
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get into court you know this idea of an
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arbitrary and capricious review where
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ultimately you have to show that they
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didn't act reasonable and denying the
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claim if your own doctor's not going to
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support you there's no greater
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reasonable basis and denied than agree
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with someone's own doctor so you really
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want to work that out that's why a lot
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of times when people will call us prior
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to falling they're thinking about it and
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we ask have you been to the doctor are
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you going to the doctor if they haven't
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you know the advice will often be you
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need to start getting into the doctor
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you need to have these conversations
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with the doctor you know
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as to what's going on because
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you're going to get a file review the
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chance of the insurance company sending
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you for a physical review is going to be
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limited it happens it's but more often
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than not they're going to just review
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your medical records and that's going to
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be the end-all be-all so if you have
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nothing there or very limited the
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chances of success is going to be small
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um caesar i want you to explain
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something i always tell the the
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claimants when they call me i go your
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claim is only as good as it is on paper
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and why
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you know why do we have that here as a
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way that when steve worked when steve
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was talking that's exactly what was
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going through my head and it's it's uh
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the the
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the fact is is that you're unlikely in
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most in most claims now there are are
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certain claims now that more insurance
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companies are sending field agents to
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meet with the insureds or sending them
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like you said to an independent medical
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exam or something like that where
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they're
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where they're setting eyes on you
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they're meeting you they're talking to
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you they're going through your claim but
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that really isn't going to change very
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much in terms of the course of your
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claim
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if your medic if the medical records
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don't really paint a picture of a person
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who's having limitations who's having
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problems
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to the extent
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that they're not able to work in their
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occupation or in in in any occupation
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so that's how critical it is i mean you
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you are in these disability claims only
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as disabled as you appear in in your
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medical records in in that
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administrative record if you one day
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have to go to court because that federal
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judge isn't going to see you he's not
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going to hear any testimony about your
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about your claim or about your case or
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about how disabled you are all he's
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going to do is review those medical
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records and review a claim file or
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administrative record that's produced by
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the insurance company so but caesar i
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mean this happens all the time
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number one most people don't like going
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to the doctor that's a given right
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number two a lot of people
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they're not complainers
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so you know here you are you don't want
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to go to the doctor you're not a
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complainer almost all of our clients
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don't want to be on disability because
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you're giving up at least 40 or 33 and a
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third of your you know you can only
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qualify for 60 or 66 percent of your
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income
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um so
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you know three things i don't want to be
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you know you you don't want to be
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unclaimed you don't want to go to dar
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you don't want to complain when you do
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go to the doctor now you meet a doctor
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who doesn't document the file that well
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and
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you're
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you'd want to go and file and we get the
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records you know at some point time
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we're like yeah we see you went to the
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doctor but the doctor didn't really put
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much here and your claim doesn't look
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strong on paper
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is that person
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you know going to be able to to collect
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i mean how do you help that person
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well sometimes it's a function of
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building up that that file it may not
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happen at the first go around they they
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may get denied when that claim gets you
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know filed
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it may have to get built up through an
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appeals process we may have to go
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through um sending that person through
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some sort of functional capacity testing
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or sending them through a vocational
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assessment of some sort to
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really
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break down the physical demands of their
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occupation or or whatever the standard
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is at that point in time
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but um
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yeah i mean it's it's
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in terms of helping them i mean you have
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to look at kind of the complete picture
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and assess what's going on and decide
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what it needs and then steve the
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complete opposite of that scenario i
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just presented was the client who calls
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you has been going to the doctor for two
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years
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working whatever job they are very few
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you know missed days and then reaches
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the point where they say i can't do it
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anymore and disability carrier says to
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you well you've been complaining for two
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years you've been going to the doctor i
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don't see any reduction in what you're
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doing
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why now are you disabled and how do you
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address that that's that's tough what
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changed you know what change and people
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do you know work and i had a client
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last year
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paraplegic from an accident wheelchair
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bound had very limited use of the upper
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limbs and everything right and he was
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able to go to work great work ethic did
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not miss a day of work he would work
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extra to get his projects done you know
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stellar performance reviews and when he
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filed his claim with with the insurance
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company he you know he he told them as
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much and he said well when i'm outside
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of work it's much harder to do things
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and this guy if
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realistically was killing himself to
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work and the insurance company i don't
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know if you could necessarily fault him
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because it wasn't impacting his ability
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to work these policies aren't as
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impacting your ability to enjoy your
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life it's is it impacting the ability to
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work so if you do have this history of
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being able to work not miss it not
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having performance problems you have a
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diagnosis but that diagnosis isn't
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equating to a disability for purposes of
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the policy so that's a really fine line
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and it's difficult because a lot of
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people like you said they don't want to
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be on disability they don't want to
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complain and you know i can completely
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respect that that stoic mentality of of
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continuing to work and trying to go but
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it's a double-edged sword if you don't
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think you're going to be able to work
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and your only option is this disability
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policy you got to work to make sure that
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you may not want to talk to your doctor
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and quote unquote complain but if you
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don't you're cutting your you're just
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cutting your nose off despite your face
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inability to get the benefit so it's
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really nuanced and it's it's it's hard
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for a lot of people to mentally make
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that switch of you know i can't do this
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anymore and that that's hard so there's
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really no hard fast rules answers to
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that every case is going to be so unique
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to the person right and that's what
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makes this so tricky and such a great
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question is do i qualify for disability
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because
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there's so many factors you know your
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medical history your policy you know
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what do you want to get out of the
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policy when a claimant call yeah you may
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qualify but may have a limitation that
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you're talking about a mental nervous a
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neuromuscular
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your age the benefit amount a social
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security disability set off so i'm
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throwing out all these things that we
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can just rattle off and we could talk
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for another three hours about things to
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be aware of if you qualify but
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you know these are the things when a
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claimant contacts us we know the
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questions to ask to bounce through all
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these issues quickly
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our job is to maximize the policy for
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the claimant what are your goals what do
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you want to get out of it and then we'll
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tell the claimant here's what can or
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can't happen with your policy and for us
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it's an easy you know it's an easy
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process to to know that in terms of
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getting the person to be
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approved that's a difficult can be a
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difficult process where a lot of things
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have to go the claimant's way and if
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something is not right you guys know the
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disability insurance company is going to
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use as an excuse
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to deny the claim so
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that's the challenge and i hope that the
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people who are watching this video
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understand that it's not as simple as
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just when you want to get the coverage
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so if you need help anywhere in the
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country feel free to call us for a free
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consultation
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and we welcome the opportunity to speak
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with you
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you
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