New York Insurance Attorneys

1. I disagree with a benefit denial or termination decision made by my long term disability insurer, so can I “take ‘em to court”?

Although exceptions exist, chances are that if you’re insured through a group plan in which you were enrolled as a benefit of your job, you cannot simply sue your insurer. Instead you must first pursue what’s called an “administrative appeal” -- essentially a written request asking your insurer to reconsider its decision. Depending on the terms of your specific plan, you may even be required to file a second appeal if your first one fails (additional levels of appeal may be offered, but not required). Only when the administrative appeal process has ended are you then entitled to sue your disability insurance company.

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2. Before I prepare my appeal, can I get a look at what’s in my insurance company’s file?

Absolutely. If requested, insurers are required by law to make a copy of their entire file available to you free of charge.

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3. What should I include with my appeal?

There are no formal requirements, but when preparing to submit an administrative appeal you should bear in mind that it may be your final opportunity to come forward with new information -- like medical records, correspondence from your treating physician(s) or an award letter from the Social Security Administration -- that supports your position. This is because if you decide to start a lawsuit (after your appeal fails), it is likely that the judge will refuse to consider anything that was not previously presented to the insurance company.

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4. Are there any deadlines that I should be concerned about?

If you are required to file an administrative appeal, you must generally do so within 180 days (roughly six months) of the date on which you received the benefit denial/termination letter. If you are already beyond the deadline, you may still be able to appeal (if, for example, your insurer’s benefit denial/termination letter failed to tell you about your need to appeal and/or the deadline for doing so).

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1. Can I get Social Security disability benefits even if I never worked?

Even if you haven’t worked, you can get benefits from Social Security if you are disabled and have both low level income and very little savings or other assets. The Supplemental Security Income (“SSI”) program offers monthly benefits up to $785 for New York residents to persons with physical or mental conditions that prevent them from doing any regular job on a sustained basis, regardless of whether they have worked before. Applicants must have less than $2,000 in assets and a low level of monthly income. The house or apartment the applicant lives in doesn’t count toward the asset limit.

SSI also is available to children who have physical or mental problems that cause marked limitations in the things they can do. Modified income and resource limitations are applied to their parents. Persons 65 years of age or over, who have low income and limited assets may be eligible for SSI even if not disabled.

Social Security also offers benefits in some cases to survivors of deceased workers and to dependents of workers who are disabled. Strict SSI asset and income limits don’t apply to these programs.

Applications for SSI and other benefits can be made at your local Social Security office or by dialing Social Security’s 800-number: 1-800-772-1213. Social Security’s website- www.ssa.gov - offers more detailed information about eligibility.

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2. What kind of illnesses would qualify me for Social Security disability?

Any diagnosed illness, whether physical or mental, may be the basis for an award of Social Security disability benefits. But a diagnosis is not enough. To win benefits, your illness must be serious enough to prevent you from returning to your past work and serious enough to keep you from doing any other work in the national economy, given your age, education, and work experience.

Key to any disability claim is medical evidence. Social Security wants to see information from your doctor giving your diagnosis, symptoms, test and clinical exam results, and treatment history. Also needed is a statement from your doctor about how much your illness limits the things you can do. Roughly speaking, a person under 50 years of age with a physical illness only must prove inability to do a “sedentary” job -- like a desk job – that requires mostly sitting, some standing, and lifting up to 10 pounds. Disability can be found in mental illness cases when the applicant has marked problems with concentration, completing tasks, dealing with other people, or other basic work-related functions.

Social Security must consider the impact of all your physical and mental problems together. When applying for benefits, every physical and mental problem you have should be described.

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3. I applied for Social Security disability and got denied. Is it worth appealing the case?

First level decisions on disability applications are made for Social Security by a New York State agency. The agency has a poor reputation among disability advocates who think that it wrongly denies the claims of many very disabled people.

If your claim is denied at the first level, don’t give up! You have the right to get the denial reviewed at a hearing with an Administrative Law Judge (“ALJ”). A request for an ALJ hearing generally must be made within 60 days of the day you get your denial notice. You can make the request at your local Social Security office or through Social Security’s 800-number, 1-800-772-1213.

At the ALJ hearing you’ll have a chance to meet the judge face-to-face, present new evidence of your disability, and talk about why you can’t do your past jobs or other work in the national economy. Hearings are private and relatively informal, and you can bring an attorney or other representative to assist you.

Every judge and every case is different, but the average number of cases won at the ALJ hearing level is well over 50%. If the judge turns you down, further appeals are possible. With Social Security, persistence often pays off.

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