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ERISA Disability

ERISA Disability

Very few attorneys handle ERISA governed insurance claims, which is surprising since it covers almost every American in some way, shape, or form. ERISA stands for the Employee Retirement Income Security Act.  This is a federal law passed by Congress in 1974. Unless you work for a governmental or church entity, then it most likely covers you. ERISA governs most employee benefits, including, short-term disability insurance, long-term disability insurance, life insurance, pensions, and health insurance.

ERISA requires employee plans to provide participants with plan information including important information about plan features and funding; provides fiduciary responsibilities for those who manage and control plan assets; requires plans to establish a grievance and appeals process for participants to get benefits from their plans; and gives participants the right to sue for benefits and breaches of fiduciary duty.

Most importantly though, it changed the way that insureds must appeal and litigate the denial of their claims, and it removed many of the state law penalties for unfair or unreasonable decisions made by insurance companies.

Unlike state law insurance claims, if your claim is governed by ERISA you must go through the insurance company appeal procedures.  Unlike a state law governed insurance claim, you will not get a normal jury trial.  There are a lot of traps for inexperienced attorneys or for those who think an ERISA claim is just like any other civil case.

Why should you contact an experienced ERISA attorney?

If your disability, insurance, or other ERISA governed claims are denied then it is critical to hire an attorney that knows how ERISA works to do your appeal.  You must remember that under ERISA, the burden of proving that you meet the definition of disability lies with you, the insured.  The insurance company does not have to prove the case for you.  And the only opportunity to prove your case is during the claims process – either upon application or during the appeal.  Once the appeal process is over, and you are forced to file a lawsuit, the claim file is mostly closed and absent extenuating circumstances you may not be able to add any information to the record.  This means that the Judge will not review documents not sent to the insurance company for its review.

Think of it this way:  When you open your claim, the insurance company puts your name on a cardboard box at insurance company headquarters. Everything that you send to them goes into that box. Everything your physicians send to them goes in that box.  Everything that the insurance company produces to review your claim goes into that box.  If they deny your claim, then you will have 180 days to appeal.

An experienced ERISA attorney will request the claim file and review it with you.  This is what we do.  Then we analyze the medical facts, the insurance policy language, and what the insurance company did to review your claim.  Then we put together an appeal plan to make sure that you prove your case.  This could require additional testing, testimony from your physicians, or a vocational workup.

We must prove your case before the claim file is closed.  Then if the insurance company denies your appeal, we will have a great cardboard box of information to show the Judge when we file a lawsuit.  Simply sending an appeal letter often does not work and results in the insurance company just rubberstamping the appeal denial.

Attorney Aaron Engle has handled hundreds of disability appeals.  Aaron knows how to build your case and prove to the insurance company and a Federal Judge that you have met the burden of proof. Aaron has spent his entire career helping people with ERISA and non-ERISA disability claims. He enjoys going through the medical records, reports, and insurance company arguments and then putting together a response that honors your story and shows why the insurance company made the wrong decision.

What makes an ERISA claim so hard to handle?

Appealing or litigating a long-term disability claim denial, governed by the Employee Retirement Income Security Act (ERISA), can be a complicated process. To overturn a denial, or win a case in litigation, you really need an attorney experienced in the intricacies of ERISA like Aaron Engle Law.

Below, we will look at an example of ERISA disability claim, how ERISA works, and why having an experienced ERISA disability legal team on your side can be the difference between collecting the benefits you need to support yourself and your family.

Attorneys who specialize in ERISA disability claims advocate for disabled people and assist them in obtaining the benefits they are entitled to from disability insurance companies.

This area of law is ever-changing, the deadlines for appeal are strict, and insurance companies use all manner of tricks to deny claims.  In addition, the terms and conditions of the policies vary and contain exclusions, limitations, and changing definitions of disability.

If your short-term (“STD”) or long-term disability (“LTD”) claim is denied, then you will have only 180 days to appeal.  This is the most important stage of the process, and when you should contact someone like Aaron Engle Law.  We will request your claim file and review it with you at no charge.  We then put together an appeal plan after you sign a fee agreement outlining the terms of our representation.

We then put together the best appeal possible to get the denial overturned or position your case in the best possible way for litigation should the appeal be denied.   This may include testing, expert reports, and other evidence to prove your disability.  The appeal plan will vary depending on your medical condition.  We have appeal and litigated claims for all types of medical conditions from Multiple Sclerosis, Fibromyalgia, Lupus, Cancer, Chronic Fatigue Syndrome, Long Covid, Rheumatoid Arthritis, Brain Injury, Chronic Migraines, Depression and Anxiety, and many other conditions.

Understanding your rights and getting legal counsel from an expert ERISA disability lawyer is crucial if you have been denied disability claim benefits because ERISA only allows for one appeal.  Once the appeal process is concluded, absent some extreme circumstances, you cannot add any more evidence to the record for the Judge’s review.

An attorney can assist you in navigating the complicated appeals process, gathering the required information to support your claim, and advocating on your behalf to ensure that you obtain the benefits you deserve

When does ERISA apply?

If your long-term disability insurance coverage is a benefit offered by your employer, it likely falls under the jurisdiction of the Employee Retirement Income Security Act of 1974 (ERISA). This highly complex federal law provides a lot of advantages to insurance companies and makes it hard on insureds struggling to get by with a disability.   If you work for a governmental or religious entity, then your claim may not be governed by ERISA.  Instead, it will be covered by more protective state law.

Employers who provide disability insurance are required under ERISA to establish and maintain a comprehensive plan document outlining the terms and conditions of coverage.   It is very important that you get a copy of your Summary Plan Description, as well as the applicable STD and LTD policies.

Do You Have the right to appeal a disability denial?

Yes. As noted above, if your STD or LTD claim is denied, you have the right to appeal within 180 days.  You should contact Aaron Engle Law as soon as possible because you do not want to miss the deadline for appeal.  If you do not appeal in a timely fashion, then your claim is over.  If the appeal is denied, then you have the right to file a lawsuit in Federal Court.  However, the only thing the Judge will review is the claim file maintained by the insurance company, so you really need to stuff the file with all the evidence to prove your case.

Why would an ERISA disability claim be denied by an insurance company?

Insurance companies do not like to pay claims.  Instead, they like to charge premiums.  Since ERISA does not provide penalties for improper claim denials, insurance companies practice a claims handling strategy of deny, delay, and defend.  Often, the insurance carriers like UNUM, Prudential, Hartford, Lincoln, Standard, and others will claim that the medical records do not support your claim, or that your condition is pre-existing, or that their medical professionals do not believe your doctor’s opinion.

Other claimed causes for denial may include alleged missed deadlines, incomplete or erroneous application forms, or a failure to meet the plan’s definition of disability.

Additionally, an insurance company may reject your disability claim if they consider that you can work based on their own internal standards and procedures for your medical condition. Insurance companies may have your claim reviewed by a biased physician who specializes in denying claims, minimizing your condition, and cherry-picking data that supports denial.

What is the best strategy for appealing a disability claim denial?

If you are appealing a denial of a STD or LTD claim, the more information you have the better for proving that you meet the definition of disability contained in the policy.  At the start, we request a copy of the claim file from the insurance company so that we can see the basis for the denial.  Then we put together an appeal plan based on your medical condition, your restrictions and limitations, your job, and your background, education, and training. An appeal may include:

  • Updated medical records
  • Testing
  • Vocational evidence
  • Reports from providers
  • Witness testimony
  • Photographs
  • Policy documents

We construct an appeal plan particularized to your case.

Why are disability insurance claims governed by ERISA so complicated?

ERISA law can be confusing. The law establishes minimum requirements for the creation, management, and funding of plans to safeguard the interests of employees who take part in employer-sponsored plans offering retirement, health, life, and disability policies.  Unfortunately, it is a complicated procedural statute that provides few remedies, and no penalties for insurance company bad behavior.  It also does not require employers to provide these benefits, just if they do, how the claims should be administered.

Various common policy provisions have been interpreted a variety of ways in Courts across the country.  In addition, each federal circuit court has different interpretations and legal rulings around the regulations governing ERISA, the burden of proof for insureds, and how certain medical conditions will be considered.

Furthermore, ERISA law is very technical and necessitates a thorough comprehension of the specific plan documents, administrative processes, and legal requirements that apply to every single claim. This makes it difficult for employees to manage the claims and appeals process on their own, and it can increase the likelihood of mistakes or errors leading to benefit denials.   It also has very short deadlines and strict rules for appeals.

As new rulings and regulations are made by the courts and the Department of Labor, ERISA law is also continually changing. This requires attorneys to stay current on the newest changes and adapt their practices to meet the needs of disabled clients.

Employees who are unable to work due to a disability covered by their employer-sponsored disability plan can replace some of their income through an ERISA governed disability policy. ERISA law is complex, and disability claims under ERISA might be denied or dismissed for a variety of reasons beyond your control and the understanding of your medical providers. Your long-term disability claim deserves to be handled by someone with experience of seeing through the insurance company games and knows how to prove your case.

Contact us today to learn more about how we can help!

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Long Term Disability Lawyer

ERISA Disability Lawyer

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