Long Term Disability and ERISA Claims – What You Need to Know

ERISA Long-Term Disability Plans – The Details

What is ERISA?

Passed by Congress in 1974, the Employee Retirement Income Security Act, or ERISA, was originally intended to protect employees’ right to benefits. ERISA is a complicated and complex law, which is now widely believed to protect insurers, rather than employees as originally intended. As a result, a long term disability ERISA claim can be an extremely confusing, overwhelming, and time consuming task. Often times, an experienced attorney can make the difference between a successful and unsuccessful claim. A denied ERISA disability claim is largely controlled by the insurance plan language, and can be difficult to navigate if one is not familiar with the language.

How do I know if I have long term disability (LTD) insurance?

You have LTD benefits if you personally purchased a disability package, or if your employer provided you with some sort of “package” as an employment benefit. In this case, you need to carefully read and review the details of the package your employer provided. If a copy cannot be located, you or your attorney can send a certified letter to the employer and request the package details, or Summary Plan Description (SPD). Under federal law, the employer must provide the SPD within 30 days of receiving the request. This is a must when evaluating a denied LTD claim.

I have LTD insurance. Will ERISA (federal law) or state law apply to my claim?

That depends on whether you received the insurance from your employer or from a private company. (Governmental entities differ, however). If provided by your employer, then ERISA, and therefore federal law, applies in most cases. If you purchased insurance from a private insurance carrier, then usually state law, and therefore not ERISA, will apply. Depending on your jurisdiction (state or federal) can change deadlines, the standard of review in which your case will be decided, and the timeline in which you can expect to resolve your denied LTD claim.

How do I file an ERISA claim?

Each insurance policy information or SPD will provide information concerning the procedure for filing an ERISA claim. Each employers’ claim procedure will vary slightly, but usually the employee begins by informing the employer and/or insurer that a disability claim needs to be filed. This is followed by the completion of a number of forms and other paperwork related to the claim.

What are the most important things to do before filing a LTD claim?

  1. File the claim while you are still employed (but not working) and salary is highest.

Fullest Capacity: Sometimes a disability plan will be invalid once an employee resigns. Also be wary if your employer offers a severance package; these often contain clauses that are hidden amongst legal jargon which prevent the employee from appealing a denial.

Working the Hardest: A majority of LTD policies require the claimant to prove he/she was incapable of performing their “own occupation” during the initial two years of being disabled. For example, a transition from a heavy duty/stressful position to a light duty/less stressful position prior to the filing of the claim could be detrimental to your claim because it is generally easier to present an inability to perform a heavy duty job. A good rule of thumb to follow is file your claim soon after you obtain sufficient medical evidence to support your claim, but file before you transfer to a lighter duty position.

Highest Salary: In some cases, proof of a disability comes in the form of decreased wages, meaning an employee has to earn only a certain percentage of her salary to prove disability. This is why an employee should file his/her claim when their salary is the highest. Also, as mentioned in the above paragraph, it tends to be easier to prove inability to perform a high salary job as compared to a low salary job.

  1. Obtain all pertinent medical records, review for inaccuracies, and communicate with your treating doctor(s).

Along with an experienced attorney, sufficient medical evidence is vital to a successful LTD claim. If there are inaccuracies or errors in your files, request the doctor to correct them. You may also want to sit down with your treating physician(s) and review your LTD policy with them. Obviously if your doctor does not support your LTD claim, it would be wise to obtain a new medical professional who does. In short, you want to strengthen your medical record evidence to support your case before you even file the claim.

What happens after I file a claim?

After filing the claim, you must wait for the insurers’ decision. If your claim is denied (as most of them are), you must exhaust administrative remedies, and then you may file a lawsuit to appeal the decision. Appealing a denial has it’s own set of speed-bumps and procedures which are unique to ERISA plans and should be handled by an attorney versed in ERISA law and procedure. Some deadlines to appeal a LTD denial can be as short as 60 days, so seeking the advise of an expereinced attorney for your denied long-term disability claim can me invaluable.

The author, Joshua Bonnici, is the managing attorney at BONNICI LAW GROUP, APC, who represents injured and disabled individuals fight for fair and just outcomes. Feel free to learn more and reach out for a free case evaluation, at: www.sddisabilityattorney.comhelp@bonnicilawgroup.com, or at: 619-259-5199.

 

Disclaimer: while the jokes may be corny and the tone casual, none of the above is intended to be legal advice, and does not amount to any attorney-client relationship. Should you wish to investigate attorney representation, please contact us for a consultation to discuss a possible attorney-client relationship. Thank you!

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