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Proving Entitlement to Long-Term Disability Benefits Under ERISA Requires More Than Just A Disabling Medical Condition

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Every good long-term disability lawyer knows that getting a claim approved requires more than just showing that her client suffers from a disabling health condition.  There are nearly two million people living in the San Jose metropolitan, and approximately 23% of those people in the workforce will require some form of disability leave during their career.  Many companies located in the San Jose area, such as Intel Corporation, Google, Apple Inc., Advanced Micro Devices, Inc., Applied Materials, Inc., offer employees group short-term and long-term disability benefits.  However, many employees are not aware of the requirements for coverage until they need to submit a claim for benefits.  Most disability plans, or insurance policies funding those plans, require claimants to establish several requirements beyond the existence of a physical or mental impairment.

One typical requirement for disability benefits is that the claimant suffer income loss as a result of the disability.  In most cases, proving income loss is not an issue.  In some cases, however, it is unclear whether a disability is the cause of income loss.  For example, in a recent court decision, Host v. First Unum Life Ins. Co., No. CV 13-11578-GAO (D. Mass. July 13, 2016), the court ruled that it was unreasonable for Unum to deny Plaintiff Host long-term disability benefits based on its reliance of verbal information Unum received from the employer about the reason for Host’s loss of income.  In this case, Plaintiff Host had alleged that his employer discriminated against him and the discrimination was the reason behind the denial of his bonus and his termination from employment.  The employer represented that it made decisions about Host’s pay and employment without consideration of discriminatory reasons.  Because of the conflicting allegations and evidence, the court believed that Unum abused its discretion by simply accepting what the employer told Unum over the phone in three separate telephone conversations.  The court ordered Unum to reconsider Host’s long-term disability claim by conducting a more detailed inquiry into the relationship between Plaintiff’s injury and his income loss.

Sometimes the income loss issue is complicated by a reduction in hours prior to the time an employee files a disability claim.  Many full-time employees who experience a disabling medical condition will attempt to continue working on a part-time basis. Insurance companies trying to find a way to reduce their liability for a long-term disability claim will sometimes argue that they should pay benefits based on a claimant’s reduced salary, rather than the salary based on full-time employment.  In these situations, it is important that claimants consult with a knowledgeable ERISA attorney about how disability benefits should be calculated under their employer’s group disability plan.

The attorneys of Kantor & Kantor LLP represent employees from all over the Bay Area – including San Francisco, Oakland, and San Jose – in their ERISA benefit claims.  Our knowledge of the major Bay Area employers and their disability plans gives us a unique advantage in the representation of clients with long-term disability claims.

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