ERISA is short for Employee Retirement Income Security Act, established in 1974. It’s is a federal law under the US Department of Labor that “sets the minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in the plans.” Unfortunately, it doesn’t always work that way.
ERISA governs long-term disability policies and only applies to most private employers that offer benefits. It was created to ensure that plan administrators didn’t misuse pension and other employee funds. Public (governmental) or church employees (including church-owned hospitals) and private policies are excluded. ERISA only establishes minimum standards for employers who do offer benefits for their employees. It doesn’t require them to offer benefits.
ERISA And Long Term Disability Policies
A lot depends on what your company and the policy calls “disability.” Research your policy and find out exactly how yours defines it since it could determine if you can get LTD and for how long.
Some policies say “any occupation,” which means you’re unable to work at any job. “Own occupation” indicates that you can’t work in your current occupation, but you could work in a different one. (For instance, an injured construction worker who becomes a project manager.) Some policies go from “any occupation” to “own occupation” after 24 months, meaning you could work another job, even if you can’t work in the one you had before.
Claim denials are common for even the most legitimate disability cases.
ERISA means that if your LTD plan is employer-funded if you should need to file suit, you will:
- Have a hearing with judge, but no jury
- Not be awarded attorney’s fees
- Not be able to recover any damages
- Likely to be ruled against in a court proceeding
Plan administrators are given considerable leeway in the administration of a plan.
How ERISA Can Keep You From LTD
It was intended to “protect” your rights, but ERISA ends up protecting the rights of the insurance companies. ERISA preempts most state law “bad faith” lawsuits, denying you the right to sue your insurance company should your claim be denied. Unlike a personal injury suit, where you can sue for damages, attorney’s fees and other compensation, ERISA prevents you from doing that. The most you can receive from a lawsuit would be the monies you were originally due when the insurance companies denied your claim to begin with. In the administrative hearing, the judges can only determine if the insurance company committed an “abuse of discretion.”
ERISA has complex rules and regulations that must be followed exactly, and deadlines that must be met without exception. Miss one deadline, or make one mistake in your claim, and the claim will be quickly denied without any opportunity to appeal or reopen your case.
Your employer may have additional requirements, with deadlines, for you to follow before you can access LTD. Ask for any and all related documentation so you can review it yourself. Deadlines and other requirements should be detailed in these documents, so read them carefully and take note of all deadlines you need to be aware of.
Your Doctor
When submitting your LTD claim, you’ll need to prove your disability. Before you file, you’ll need to have copies of all medical records, test results, X-Rays, your doctor’s communications with the insurer, and any other medical evidence related to your case. If you find errors in any of your records, write your doctor a letter and request that they be corrected.
If your doctor declines to help you in your disability case, find another one. A doctor who does support you in your claim can’t guarantee a successful outcome. But a doctor who doesn’t support you can easily sink your claim.
Submit All Evidence In Your Original Claim
Should your case proceed to federal court, you will NOT have the opportunity to submit additional evidence. The judge is limited to whatever is in your claim file. Neither you nor your doctor will be allowed to testify. Make sure that all relevant evidence—medical reports, testing, expert opinions, evaluations, etc.—is included in your claim. Include more favorable evidence than you think you need while the claim is open to ensure it’s complete.
Deadlines Count
Insurers have specific deadlines for filing claims as well as appeals. ERISA appeals are complex and detailed.
The Herren Law Firm can help you with your application, appeals and help you get the long-term disability benefits you need. Contact us today at 713-682-8194 to schedule your free consultation. There’s no obligation and no up-front fees. We only collect if we win your case.
