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Experienced Disability Insurance Lawyer in Miami, FL If you have suffered an injury, illness, or other condition that has rendered you disabled, then it’s likely you are entitled to benefits pursuant to your disability insurance policy.  In reality, however, most insurers attempt to avoid having to payout disability benefits (even if you are reasonably entitled to such benefits) by rejecting initial claims. To successfully obtain disability benefits, then, we encourage you to consult with an experienced Miami disability insurance lawyer here at Ver Ploeg & Marino for guidance. We understand the challenges facing disability claimants, and the steps necessary for securing the benefits to which you’re entitled.  When a disability insurer denies your claim, we work tirelessly to challenge the adverse outcome and go through the processes — both internal and litigation-based — to resolve the matter favorably. Pre-Existing Condition Issues Perhaps the most common roadblock to securing disability benefits is the limitation on pre-existing conditions.  If you had a pre-existing condition linked to the disability at-issue when you signed on for disability insurance coverage, then that will preclude you from the receipt of benefits for the disability at-issue. Further, if you did not disclose the presence of a pre-existing condition, insurers will look back (from six months to a year, or more) at your medical records prior to the insurance coverage to determine whether you had the pre-existing condition and simply did not report it when signing on to the disability insurance policy. If they discover that you were […]

As Miami Disability Insurance Lawyers, we stay up-to-date on trends in the area of Disability Benefits. Several topics that have been gaining attention include employee engagement,  automation, and marijuana.  Employers are grappling with these issues, all of which are likely to impact disability insurance benefits for employees.  From increasing awareness of mental and behavioral health to learning to embrace technology while still maintaining a human connection between employer and employee and understanding the interplay between state and federal laws on medical marijuana use in the workplace, the needs and concerns of employees are being heard and addressed in new ways, while employers reap the benefits of employee loyalty and commitment. Employee Engagement Increasing employee engagement and participation with group benefit programs is a hot button for many employers.  This is not surprising considering that employee benefits are often an employer’s second largest expense, after labor.  Employers are exploring ways to increase productivity, while generating loyalty and commitment.  Examples include on-site day care, financial wellness, and other initiatives to help employees focus on work and reduce stress.  Incorporating systems and strategies for addressing employee mental health and well-being is emerging as a key component of employee engagement.    Automation New technologies are poised to radically change areas of labor, including disability programs. At the same time, however, employers and employees are concerned about losing a sense of human connection to the workplace.  Employers are responding by offering customized benefits, including enhanced disability programs, and introducing automated and digital technologies to the […]

Miami Disability Insurance Lawyers If you’ve had your disability insurance claim wrongfully denied, undervalued, delayed, or otherwise mishandled by your insurer, then you may be feeling overwhelmed, and for good reason.  Though your priority should be managing your health in the wake of a disability, it’s critical that you secure benefits that will serve as “income replacement” if you cannot return to work. Insurers are frequently aggressive about denying claims, and in fact, they often wrongfully deny disability benefits claims that are legitimate.  Insurance companies may feel justified in making denial decisions due to the insurance policy including a strict “any occupation” definition of disability.  It’s important that you understand what “any occupation” disability insurance is and what circumstances may allow you to secure benefits. What is “Any Occupation” Disability Insurance? Private disability insurance plans generally feature one of two different definitions of a disabling condition: any occupation and own occupation. Own occupation allows for the receipt of benefits in the event that the policyholder is incapable of performing the material duties of their existing occupation.  By contrast, any occupation only allows for the receipt of benefits in the event that the policyholder is rendered incapable of performing the material duties of any occupation for which he or she may reasonably become qualified. Any occupation disability insurance therefore requires that the policyholder establish that they are impaired to the degree that they cannot secure an alternative job for which they are or can become reasonably qualified. Reasonably Qualified to Perform […]

In some insurance disputes — disability insurance disputes included — policyholders may be surprised to find that their coverage is actually inadequate to pay for their losses.  Insurance agents are not always scrupulous or comprehensive in explaining the terms of the policy that you purchased.  In an effort to make the sale, the insurance agent may be hesitant to explain the contours of such coverage and what benefits you are likely to obtain, and in fact, the insurance agent may recommend a policy that is fundamentally inadequate for your needs and preferences. Fortunately, Florida law gives policyholders the right to sue and recover damages when the insurance company and/or their representatives have misrepresented aspects of the policy. Let’s explore some of the basics. Insurance Agents Have a Duty to Accurately Represent Coverage In Florida, insurance companies and their various representatives — including insurance agents, of course — must clearly and accurately explain the terms of the policy that they’re selling.  They may not misrepresent any relevant aspect of the policy, such as the amount of coverage.  Whether the company representative misrepresented information to you depends on the circumstances of the case. For example, if a simple statement made by the insurance agent would not have misled the average, reasonably prudent policyholder, then in all likelihood, the agent has not violated their duty and misrepresented information.  On the other hand, if the representative knew that your reasonable expectations of the policy were different than the actual terms of the policy, then […]

As a disability insurance policyholder, whether you are entitled to secure benefits for your disabling illness, injury, or other condition will depend primarily on your ability to demonstrate that your circumstances qualify you as “disabled” pursuant to the language of your insurance plan.  Insurers are incentivized to interpret plan definitions (and the severity and extent of your condition) in a manner that is unfavorable to your interests — if the insurer can plausibly deny your disability benefits claim, then they can save substantially on costs that would have otherwise been paid out to you. Given the importance of the “disability” definition for your benefits claim, and the likelihood that your insurer will attempt to muddy the waters by interpreting it — and your condition — in a way that is opposed to your interests, it’s worth understanding just how disability is defined in your plan so that you can effectively counter the arguments made by the insurer. Let’s take a look. Variable Definitions of Disability Disability insurance plans either have an own-occupation or an any-occupation definition of what constitutes a “disabling” condition.  The definition described in your plan can have a significant impact on your ability to recover benefits. Own Occupation When a disability insurance policy includes an own-occupation definition of a “disabling” condition, claimants may be awarded benefits so long as they can show that their illness, injury, or other condition has caused them to be unable to perform the major duties of their current occupation. For example, if […]

In Florida, and throughout the country, mediation of complex insurance disputes (whether a disability insurance dispute, health insurance dispute, or otherwise) is a common strategic option employed to resolve the conflict before litigation.  Through the mediation process, the involved parties — insurer and policyholder — can negotiate a favorable settlement that satisfies their expectations while avoiding the hassles and difficulties typically associated with insurance litigation. Litigation May Be Fraught With Difficulties Litigation can be somewhat risky for many plaintiffs, whether in the insurance context or otherwise.  Going through with trial litigation can be time-consuming, expensive, emotionally frustrating, and uncertain.  For example, if you have suffered a disabling injury and are unable to return to work, then the prospect of litigation — and the possibility of a long and demanding trial process — may be undesirable. Generally speaking, insurance policyholders hope to secure benefits within a reasonable timeframe.  Litigation not only extends that period, but may expose the policyholder (and their insurance dispute) to public criticism, thus damaging other aspects of their life.  Thus, where possible, a negotiated settlement is usually preferred. How Mediation Can Lead to a Favorable Settlement Litigation is fundamentally hostile — each side is arrayed against the other, constantly seeking an advantage.  By contrast, mediation is a voluntary process where the disputing parties attempt to negotiate a settlement compromise in a more collaborative environment.  During a mediation, a neutral third-party mediator is selected.  The mediator will hear out the arguments presented by each party (in a less […]

Residual disability benefits are common, in Florida and throughout the country — whether in the form of an insurance rider on a total coverage plan, or as a standalone income replacement policy — as a means with which to ensure that the claimant can secure at least some benefits after suffering a disabling event that is not necessarily catastrophic. For example, if you are injured in a car accident, then you may suffer a disability in the form of back spasms, but this disability may not be “total” in the sense that you might be capable of performing your existing job.  Residual benefits open up insurance coverage, to an extent, by allowing you to recover for disabilities that effect certain job duties, but that do not necessarily prevent you from working altogether. Despite the fact that residual benefits are intended to fill the coverage gaps typical of total disability insurance policies, many insurers will challenge residual benefits claims and make it difficult for claimants to secure the benefits to which they’re entitled. Qualifying for Benefits Whether you actually qualify for residual benefits depends on the particularities of your insurance plan — there is no universal, consistent baseline for residual benefits, as plans can vary quite substantially.  Residual benefits are a form of partial income replacement, and as such, many plans involve a showing of income loss of a sufficiently significant degree.  For example, your plan may require that you demonstrate — post-disability — that your income has fallen at least […]

Disability insurance coverage can surprise many policyholders who put too much trust in their insurer to “do right” by them.  All too often, disability insurance policyholders believe that they are well-protected by their private policy, only to find that their insurer is taking steps to avoid or minimize the payout altogether. In many cases, the insurance contract itself includes language that could expose the policyholder to a dispute down the line, when they have actually been disabled.  It is increasingly common for insurers to include a limitation on benefits for disability claims that are premised on psychiatric conditions (i.e., mental disorders) — this limitation is commonly referred to as the “mental and nervous” provision. Let’s briefly consider the fundamentals. How the Mental and Nervous Provision Works Claimants may be initially confused by the application of the “mental and nervous” provision in their insurance policy, but it’s rather simple in effect.  The provision essentially limits the duration of benefits payments for disability claims where the cause of the disability at-issue is based exclusively on a psychiatric condition. Generally speaking, only the length of payments are limited, not the amount.  For example, if you have been suffering from a substance abuse condition (say, alcoholism), and the addiction is so serious that it has effectively rendered you disabled and unable to work, then you may be entitled to benefits, but only for a limited period of time — perhaps a two-year period. Insurance policies can vary quite a bit, but as a general […]

Disability claimants may be surprised to find that — despite the fact that they have never lapsed on insurance payments and are submitting a reasonable disability benefits claim — the insurer response is unaccommodating.  Disability insurers employ a number of questionable tactics in order to force the claimant into a vulnerable position.  For example, if you have been rendered permanently disabled due to a degenerative condition, the insurer may deny your claim, delay your claim, or undervalue your claim.  Doing so gives the insurer substantial leverage during later negotiations. Oftentimes, disability insurers use the “lump sum buyout” to avoid having to pay long-term benefits, or to end the insurance dispute altogether.  Lump sum buyouts are not necessarily unfavorable to the claimant, however.  Accepting a lump sum buyout is a perfectly reasonable option in some cases. Let’s explore the basics of an insurance buyout. What is a Lump Sum Buyout? In the disability insurance context, a lump sum buyout — otherwise known as an insurance settlement — is effectively an offer to purchase the claim at-issue.  Stated simply, the insurer offers to pay some agreed-upon amount in a lump sum, and you (the disability claimant) must agree to abandon your legal rights under the policy.  You will not be entitled to receive further benefits under the policy, nor will you be entitled to sue the insurer for damages. Lump sum buyouts are often used as a way to clean up what may appear to a messy insurance dispute.  For example, rather […]

In 1974, the Employee Retirement Income Security Act (ERISA) was enacted, thus creating new standards governing private employee benefit plans — such as employer-sponsored disability, health, and welfare insurance, among other plans.  In Florida and elsewhere, ERISA does not require that employers purchase private insurance coverage for their employees, but it does impose a stricter set of rules on such plans so that employee-policyholders are protected from the potential abuses of plan administrators and others. If you are a private employee in Florida, and you are a participant in an employee-sponsored benefits plan, then in all likelihood your plan is ERISA-covered.  This not only ensures that your plan will be governed by federal law (i.e., ERISA regulation), as opposed to Florida law, but also subjects you to various advantages and disadvantages when it comes to litigating claims against the insurer. Consider the following. Fiduciary Duties Give Rise to Legal Action ERISA establishes a range of fiduciary duties and obligations, which gives policyholders new opportunities to sue and recover damages for fiduciary violations.  For example, suppose that you are a policyholder in an employer-sponsored welfare plan.  You later discover that the funds were mishandled by the fiduciaries (i.e., the plan administrator and their agents), and this will have a substantial impact on your later benefits.  You would be entitled under ERISA to sue the fiduciaries and secure damages as compensation for your various losses. Florida Bad Faith Law is Preempted Under state law, section 624.155 of the Florida Statutes establishes bad […]