Common Roadblocks to Securing a Payout Under Your Disability Insurance Policy

Fri Jun 19th, 2020 on     Disability Insurance,    

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 diagnosed with the pre-existing condition during that “look back period,” for example, then they are well within their rights to deny your claim for benefits.

In many cases, however, insurers are quick to attach the pre-existing condition tag to any problematic medical status that is distantly linked to your current disability.  For example, if you had long-term back pain, and then you later suffer a debilitating back injury in a car accident, the two issues may be completely uncoupled from one another — but the insurer may attempt to draw a connection between them to avoid having to payout benefits for the accident-related back injury.

Determination of “Disability” Status

What constitutes a “disability” varies significantly from policy-to-policy.  Generally speaking, however, a disability is an injury, illness, or condition that prevents you from working for a period of time.  Some policies allow for benefits if you are still capable of working, but only part-time (or in some other limited capacity).  Other, stricter policies require that you prove that you cannot perform any of the primary job duties whatsoever — and even stricter policies require that you prove that you cannot work in any capacity (in order to qualify for disability benefits).

There is significant variation, and as such, there is also a great deal of confusion and ambiguity in how these policies are written (as insurers often attempt to “sell” the policy while giving the impression that it provides broader coverage than it actually does).  If the disability definition is ambiguous, it’s worth noting that Florida courts interpret ambiguous provisions in favor of the policyholder, so you will be in an advantageous position when litigating against the insurer.

Self-Inflicted and Risky Acts

When a policyholder engages in highly risky activities (i.e., skydiving, bungee jumping, street racing, etc.) that are likely to result in injury, then they may not subsequently make a claim for disability benefits on the basis of injuries linked to that activity.  The large majority of disability insurance policies exclude coverage for such acts, though it’s worth noting that there is quite a diverse range of contract language from policy-to-policy.

For example, your insurance policy may not specifically enumerate certain “high risk” activities for which the resulting disability is excluded.  If so, then you may be able to argue — with persuasive testimony from various experts — that the activity was not excessively high risk, and that you should therefore be covered by the policy.

Notably, self-inflicted injuries are also not covered.  If you are disabled due to actively engaging in a street fight with someone, then the subsequent disability claim would almost certainly be denied by your insurer (and justifiably so) on the basis that you intentionally assumed the risk of injury.

The Mental/Nervous Exclusion

Generally speaking, most disability insurance policies include limitations for mental health conditions, such as anxiety and depression.  Some policies outright exclude such conditions from coverage, while others allow for coverage, but only for a limited period of time (i.e., for a year or two), after which the benefits will end.

If you are suffering from a mental/nervous condition, then you may not necessarily be left in a lurch.  In fact, many instances of mental/nervous disability have physical ramifications.  For example, long-term, severe anxiety may “activate” heart complications and other systemic physical issues.  If you can demonstrate the existence of a covered disability (even if its onset is linked to the mental/nervous condition), then you may be qualified for the standard benefits available through your disability policy.

Contact VPM Legal for a Comprehensive Consultation

Here at Ver Ploeg & Marino, our experienced attorneys have spent decades working with a range of policyholder-clients — including disability claimants — to help them secure the benefits to which they’re entitled.

We have not only built a winning reputation in the Florida litigation community, but have also developed an extensive network of experts who can provide valuable testimony in support of your disability claims (i.e., medical, vocational).

If you’d like to speak to a skilled Miami disability insurance lawyer at VPM, we encourage you to contact us as soon as possible to schedule a consultation.  During the consultation, we will evaluate the disability claim and identify the next steps necessary to effectuate your rights under the policy.

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