LTD and ERISA Lawyers: Riverside, Orange & San Bernardino Counties
When There Are Different Insurers for Short-Term and Long-Term Disability
When There Are Two Insurers
Under an ERISA disability plan, there may be two different insurance companies: one insurer for short-term disability (STD) benefits and another insurer for long-term disability (LTD) benefits.
For example, in one of our recent cases, the STD insurer was Sedgwick and the LTD insurer was MetLife. So, what was the problem?
The problem arose after our client applied for and was approved by the STD insurer, Sedgwick, to receive STD benefits, which Sedgwick paid throughout the STD period. So far, so good. But after our client completed the STD period and applied for LTD benefits, he found that the LTD claim was administered by a different insurer, in this case, MetLife. MetLife had our client's file reviewed by a doctor they hired, and that doctor determined that our client had not been disabled at all during the STD period.
A prerequisite for LTD benefits, under our client's disability policy, was that he be continuously disabled throughout the STD period. Although Sedgwick determined that he was (and paid him benefits), MetLife decided that he wasn't. On that basis, MetLife denied LTD benefits. Sometimes there is a "paper review" or review by a physician or nurse that is hired by the insurance carrier that has reviewed the insured's medical record and opines that the limitations are "not as severe" or have improved and therefore using that as an additional basis for denial.
Can They Do That?
The short answer is “yes, they can.” Even though the first insurer, Sedgwick, found that our client was disabled throughout the STD period, the second insurer, MetLife, determined he was not disabled during the STD period, and therefore ineligible for LTD benefits. Under the law, a claims determination made by the first insurer is not binding on the second insurer.
Why Do They Do This?
ERISA law permits an LTD insurer to independently decide, after the fact, that an insured was not disabled during the STD period, even after his STD insurer had previously determined that he was. The strategy here appears to be that the first insurer pays STD benefits to create the illusion that the insured's disability claim has been approved and that the insured can therefore relax and not worry so much about getting his doctors to fully document his disability in the medical records during the STD period.
Then when the STD period has been completed, and the insured applies for LTD benefits, the LTD insurer relies on the fact that the documentation in the medical record will be less than complete, which allows the second insurer to determine that the insured wasn't disabled in the STD period, and on that basis deny LTD benefits. Again, this is often done with the additional "paper review" at some point by doctors or nurses hired by the insurance carrier.
What's the Answer?
Document, document, and document your restrictions and limitations from your medical impairments consistently and accurately with as much detail as possible and avoid gaps in medical records. Don't let your guard down. Contact an ERISA lawyer who will review the basis for denial and come up with a strategy to overturn the denial of STD or LTD benefits.