Roughly 25% of the San Francisco Bay Area workforce will experience some kind of disabling illness or injury, but most of these employees will not know the terms of their employer-provided long-term disability plan until they need an ERISA attorney to help appeal a denied claim for benefits. What is important to understand about both short-term and long-term disability plans is that they contain exclusions and limitations. Sometimes it is not enough to establish that you suffer from a disabling medical condition. You might also have to establish why or how you became disabled. This is important if a disability policy does not pay benefits for injuries caused by a certain exclusion. Common exclusions include disabilities that result directly or indirectly, from:
- Suicide, attempted suicide, or self-inflicted injury while sane or insane.
- War or any act of war, whether or not declared.
- Active participation in a riot.
- Commission of a felony.
- The revocation, restriction, or non-renewal of a licenses necessary to perform the duties of your occupation.
- Use of alcohol or drugs not prescribed by a physician.
Many policies also pay limited benefits if your disability is caused by a mental illness or other conditions that are not easily verified through objective measurements. Every disability policy is different so it’s important to request the plan documents from your employer. If your disabling injury might fall under an exclusion or limitation, the insurance company will have to establish a causal link in order to deny benefits. An example of this may be found in a recent court decision, Prelutsky v. Greater Georgia Life Ins. Co., No. 1:15-CV-628-WSD (N.D. Ga. Aug. 8, 2016). The disability policy in this case provides that no benefits are payable for a loss caused or contributed to by use of alcohol, intoxicants, or drugs, except as prescribed by a physician. Prelutsky suffered a disabling brain injury from a fall that occurred while he was intoxicated. The insurer denied Prelutsky’s long-term disability benefit claim because it found that his disability was caused by his use of alcohol. The judge reversed the insurer’s decision because it found that the insurance company did not conduct a sufficient investigation that would allow the decisionmaker to reasonably find a causal link between Prelutsky’s alcohol consumption and his fall.
If an insurance company has denied your disability claim based on a disability plan exclusion, it’s important that you consult with a knowledgeable ERISA attorney about your rights under the policy and the law.