One issue that has come up in recent cases more often is the Long Term Disability soft tissue limitations in LTD claims under the Employee Retirement Income Security Act (“ERISA“).
Insurance companies are pressing a two (2) year limit on benefits in claims involving such medical conditions. If the limitation is in the policy, they have the right to enforce it. It is your employer who has allowed such language to save on premiums.
How Insurers Use Soft Tissue Limitations to Deny Claims
The limitation in question is usually found in policy language addressing similar limitations, such as claims based on “mental/nervous” conditions. As limitations of this type have a negative impact on your insurance coverage, the language of the limitation is construed. Conversely, any exceptions to the limitations should be construed broadly by any court addressing the issue.
Common Soft Tissue Conditions Affected by the Limitation
The Long Term Disability soft tissue limitations involved include:
Low back pain
Postlaminectomy syndrome
Pain in the legs
Myalgia
Fibromyalgia
Pain in the hips
Long-term use of opiate analgesics
Cervicalgia
Pain in the thoracic spine
Chronic herniated nucleus pulposus
Severe lumbosacral radiculopathy
Sciatica
L4-5 disc herniation with an annular tear
Bilateral foraminal stenosis
C3-4 and C6-7 disc bulges with disc herniation
Cord impingement
Bilateral foraminal stenosis
And others
These significant medical conditions can indeed permanently remove a person from the workforce. Insurance companies must believe it is too easy to defraud them of soft tissue claims, but the expansive interpretation of this language by insurance companies is egregious.
Cases involving surgical spinal intervention cannot be faked. Cases with diagnostic testing supporting the condition’s existence cannot be fairly described as “soft tissue” but are treated as such.
Reviewing Your Policy for Soft Tissue Limitations
If your claim involves any of these conditions, you must carefully review the plan documents to see if there is such a limitation. If there is, you must consider the exceptions to the limitation to see if your condition fits into any of the “excepted” classes of medical conditions.
Reviewing the language with your treating physician may be necessary to see if the limitation can be circumvented by using precise language in medical records and Attending Physician Statements. These are issues we have walked clients through regularly in the past.
Navigating the Complexities of Long Term Disability Soft Tissue Limitations
If you are facing challenges with Long Term Disability soft tissue limitations in your claim, it is important to understand your rights. ERISA benefits can be complex, and limitations placed on soft tissue conditions could unfairly prevent you from receiving the benefits you deserve. Our experienced team is here to help you navigate these issues and work through the nuances of your claim.
Get Legal Help for Your Disability Claim
If you have any questions about your Short Term Disability or Long Term Disability soft tissue limitations, contact Herbert M. Hill, P.A. today. We are a law firm located in Orlando, Florida, with a practice extending throughout Florida.
While most cases handled are for disability insurance benefits, areas of practice include various employee benefit claims. Our firm handles any claims arising under the Employee Retirement Income Security Act (“ERISA”) for disability benefits, medical benefits, retirement benefits of any sort, including pension, 401k, termination agreements, or the like, and claims arising under private disability policies.
