Workers’ Comp | Social Security | Disability Insurance | Personal Injury

DISABILITY INSURANCE

What is ERISA and what does it cover?
What do I need to know about the claim process?
When should I seek legal counsel?
What happens at the end of the appeal process?
How does my lawyer get paid?
Can I get long term disability and Social Security at the same time?

What is ERISA and what does it cover?
ERISA stands for the Employee Retirement Income Security Act of 1974. This act regulates employee benefits for most employees in the United States. Most employees have some form of employer sponsored benefit which is covered by ERISA. These benefits include:

Pensions and 401K Plans,
Health Insurance Coverage,
Long and Short Term Disability Insurance and
Life and Accidental Death Insurance.

If you are denied pension benefits, long or short term disability benefits, or other form of employer sponsored benefit, you lawyer will generally file suit indicating a breach of contractual rights occurred under this Act.
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What do I need to know about the claims process?
In order to apply for long or short term disability benefits an individual must file an application for those benefits, which is usually accompanied by one or two attending physician’s statements. The application will be available through your employer. Most policies will approve an individual for short or long term disability benefits if their doctors establish that they can no longer perform their customary job. Many disability policies have limitations on the length of time you can receive benefits, and under what circumstances. It is very important to read your own policy in its entirety in order to understand the definition of “disability” as used in your policy. The insurance company will always be looking toward suspending an individual’s benefit when they no longer meet the policies definition of disability.

Moreover many policies have an eighteen month or two year limitation in the policy, which requires an individual to be unable to perform “any” occupation past a certain period as opposed to an inability to perform their “own” occupation.

If benefits under the policy are denied an individual must appeal the insurance company’s decision within a particular time frame. It is very important to seek legal counsel during that time frame.
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When should I seek legal counsel?
You should seek legal counsel immediately after receiving a letter declining you for either short or long term disability benefits. The reason legal counsel is so critical to the case is that you have a very limited amount of time which to appeal the insurance companies decision, typically 180 days. During that appeal period all relevant documentation to your claim must be filed. This may include additional medical records, vocational evaluations, functional capacity evaluations, doctor’s depositions, physician’s statement and the like. When the time for appealing your claim is at an end no further documentation can be added to your claim file.

If you wait until after the claim process is over to hire an attorney, that attorney may no longer submit documentation for the insurance company to review, and any Judge called upon to review the decision made by your insurance company will be bound by the documents already contained in your file.

Lawyers have valuable tools available to them, which will allow them to submit documentation in support of your claim. In order to add this information, however, you must retain an attorney while you can still submit information to the insurance carrier. That is why it is so critical to hire an attorney during the pendency of the appeal.
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What happens at the end of the appeal process?
If your claim is denied by the insurance company at the conclusion of the claims process, you have the right to file a claim in Federal or State Court. We typically recommend filing in Federal Court as ERISA is regulated by Federal Law, and most insurance companies will remove the case to Federal Court even if originally filed in State Court. Once in Federal Court, an investigation into the claim will be instituted and in most cases a mediation will be set where the parties are brought together to see if they can arrive at a mutually acceptable settlement of the case.

If the parties can not agree to resolve the case at mediation, then you have the right to request a hearing in front of the Judge and depending upon the Judge, that will either be done by a bench trial or by filing Motions with the Court. Ultimately a Judge will decide whether your benefits were wrongfully denied.
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How does my lawyer get paid?
If attorney involvement in your case either results in your benefits being re-instituted or settled in a lump sum, you will pay the attorney a portion of your longer term disability benefits. Should the case move to a court room situation, and the Judge decides your case, the Judge may award you attorney fees and costs at the expense of the insurance carrier.
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Can I get long term disability benefits and Social Security at the same time?
Yes, but there is usually some offset provision in the insurance policy which results in a reduction in the amount of long term disability benefits you receive when you are placed on Social Security disability. But most LTD policies require a person to apply for Social Security as a condition of application.
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