If you are like most people and your company offers long term disability insurance and you need to make a claim for benefits because you can't work due to a serious injury or medical condition, your case falls under a federal law called ERISA (The Employee Retirement Income Security Act of 1974).
Congress originally passed this law in 1974 to protect pension funds, but like so many other things Congress does, it has expanded to cover other employee benefits, and one of those is long term disability benefits. Unfortunately, over time, courts have interpreted it and it has been used to protect insurance companies more than the employees seeking benefits.
Almost all disability insurance plans offered to employees in the private sector are governed by ERISA. Under ERISA, you have the right to file suit in federal court against the insurance company if your claim for benefits or appeal is denied. But it won't be like other court cases (and most lawyers don't even know this). You see, the case is decided based on the insurance policy and the administrative record - including the appeal and all of the evidence you submitted to the insurance company. There is usually no discovery, depositions or testimony. A federal judge decides the case, not a jury.
OK, so if you really follow our advice on how to research, formulate, draft and file your appeal based on the insurance company claim file, the disability policy definitions and a few other things, you should be good to go
Not so fast. There is another advantage the disability insurance company has - a “reservation of discretion” clause. It's not in the statute, instead the courts created it - and its a big help to long term disability insurance companies denying legitimate claims for people who can't work.
Basically, how the clause works is If your claim for benefits is denied, you still lose even if you can prove you were right in the first place, as long as there is some evidence that supports the insurance company’s decision.
In any other civil court proceeding - medical malpractice or any other case for damages from injuries, you win if a jury believes you proved your case by a preponderance of the evidence, which just means what you are claiming is more likely than not, or greater than 50%. But in long term disability cases covered by ERISA, you can have almost all of the evidence supporting your claim for benefits - 80 or 90%, but as long as the insurance company has something, they can still win under that awful clause
So your appeal is absolutely critical.
If your claim has been denied and you need to file an appeal, or if you're considering filing for long term disability benefits due to a serious injury or medical condition, call us today to talk it through: 202-393-3320. The call is free and confidential of course.