If you are employed by Community Medical Centers of Fresno and Clovis, California, you have group long-term disability insurance through your employer. Through December 31, 2018, the group long-term disability policy was issued by Liberty Mutual – Liberty Life Assurance Company of Boston. In 2018 it became Lincoln Life Assurance of Boston. Effective January 2019, a new policy was issued to Community Medical Centers by Lincoln National Insurance Company. The two policies are significantly the same, but not completely.
The policies provide long-term disability benefits to Community Medical Centers’ employees after an elimination period of 360 days. That means you have to be disabled for 360 days before you receive any benefits under the policy. That long elimination period makes sense because as an employee working in the State of California, you are required to pay for state disability insurance (“SDI”). Therefore, you already have disability insurance for one year through the State of California – SDI. However, that long elimination period does create problems for any disability claimant under the policy. In order to get long-term disability benefits you have to prove to Lincoln that you were disabled for the 360 days. You must give written notice of your claim during the elimination period. And, you must receive medically appropriate treatment and be under the regular care of a physician during the elimination period. Under the terms of the Policy, the definition of “disabled” changes after 24 months of receiving benefits from unable to do your own occupation to unable to do any occupation.
During those 360 days one or more of your regular doctors should be certifying that you are disabled from your own occupation – because that is the only way that you can get California SDI benefits. You have to keep copies of those certifications so that you can submit them to Lincoln to prove that you were disabled during the elimination period. Second, when you see your regular doctors, it is important that your doctors document in their office visit notes that you are disabled and incapable of doing your own job. After all, one or more of them will be certifying that you are disabled for California SDI purposes – and should put the same information in his or her office visit notes.
What happens if Lincoln denies your benefits, or, if after initially granting your benefits, Lincoln terminates those benefits? You have to request a “claim review” in writing from Lincoln. If your disability arose after January 1, 2019, you must seek two administrative claim reviews of any decision to deny or terminate your benefits.
The policies require that you apply for Social Security Disability Insurance (“SSDI”) and keep Lincoln informed of the status of that claim. If SSDI benefits are awarded the amount of those benefits reduces the amount of your Lincoln provided LTD benefit (with limited exceptions).
We see long term disability claims by Community Medical Centers employees denied or terminated by Lincoln for a number of reasons. Sometimes a new claim is denied because the employee did not have proof that he or she was disabled during the 360 day elimination period because he or she did not keep or submit documentation of the California SDI claim and the treating doctors did not notate the disability status in their records. Sometimes benefits are paid for 24 months and then terminated when the definition of disabled changes. Finally, while we have not seen this with a Community Medical Centers employee, we have seen Lincoln terminate claimants’ benefits after many years of receiving long term disability benefits. For example, we are currently representing a nurse from another city in California who worked for another employer who first became disabled in 2011, was paid long term disability benefits by Lincoln, and then Lincoln terminated her benefits in 2020 and denied the first of her two appeals. This nurse’s medical condition never got better; she has and continues to receive SSDI benefits from the federal government; and she certainly is not able to work. But Lincoln terminated her benefits and ignored the evidence we submitted in support of her first appeal. Why did Lincoln do this? Because it can. It takes time and effort to appeal a denied or terminated long-term disability claim. A lot of people simply don’t have the presence of mind to do their own appeals and they give up. So, it is “good business” for Lincoln to deny or terminate long term disability benefits because a lot of claimants simply give up and therefore Lincoln doesn’t have to pay them anymore.
If you are Community Medical Centers employee whose long term disability benefit has been denied or terminated by Lincoln and you need help to fight that denial or termination, call the ERISA Law Center. We are familiar with the policies Lincoln has issued to Community Medical Centers and will fight for you to get your long term disability benefits granted or reinstated.