Here at Donahoe Kearney, we believe that the clients should be informed about what's really in their ERISA long term disability insurance policy, and how they are vulnerable to having their claims denied if they ever need to file for long term disability after a serious injury or medical condition keeps them from working.
If your insurance was offered through your employer, it probably falls under The Employee Retirement Income Security Act of 1974 (ERISA), which is a federal law that governs long-term disability policies and other employee benefits.
Every case is different and because of all of the different types of medical conditions, illnesses and injuries we are at risk for, every situation is unique. But there are enough similarities in every ERISA employer-sponsored disability insurance policy, so we try to help people understand the difficulties with these cases, how to approach them and what they need to do if they ever need to file a claim under their long term disability policy.
First, you should know that the law allows the disability insuraance company a lot of discretion in deciding who qualifies (according to them) for benefits under an ERISA log term disability policy. Here are a few things we see in these policies:
• The insurance company has the “discretion” to determine your benefits - whether you qualify under the terms, conditions and definitions of the policy, how they decide that and what evidence they use. "Discretion" is one of those words, at least in the legal field, that means just about any reason you can think of to deny benefits is "reasonable."
• Manipulating your job description: what are the material and essential tasks of your job, and can you do these? If your job requires 19 things, do you prove your case and get paid benefits only if you can’t perform “each and every” important duty of your job?
• If you have a mental illness, anxiety or depression that causes or contributes to your inability to work, disability benefits are often limited to 24 months under the terms of these policies.
• The insurance company requires you to prove you cannot work through "objective medical evidence" but not all legitimate medical conditions that prevent you from working can be proved in this fashion. Objective medical evidence was typically considered test results - an MRI to diagnose a herniated disc in your back, an x-ray to diagnose a compound fracture, that kind of thing. Unfortunately, some doctors and insurance companies have taken this to mean that you need this "objective" evidence for everything and that medical conditions like fibromyalgia, chronic fatigue, chronic pain or any illness where the symptoms are reported by the patient and can't be verified by a test result are somehow suspect.
• A part time work clause: if the disability policy doesn't define part time work, usually by the number of hours or income earned, they could use this to deny your benefits because a doctor says you can work a few hours per week (and doctors make these mistakes all the time - maybe someone does have the physical capacity to work 2 hours per day with an hour break in between - what kind of job is that? It doesn't exist. But that's not the doctor's problem. He's just the doctor, not an employment counselor...)
None of these disability insurance terms are required by law, but let's face it, disability insurance companies know that if they control the terms and definitions (and employers who provide these policies don't realize or care) they can save millions of dollars by denying or terminating benefits on legitimate disability claims.
Just remember - insurance claims examiners and adjusters are trained to find ways to limit benefits. That's how insurance companies make money.
If you filed a claim for long term disability and your benefits have been denied or terminated, get a copy and see if these terms and conditions are in play. They make these cases difficult for people who can't work through no fault of their own.
But now that you know this, here's the most important tip
Don't let the insurance company just deny your benefits without a fight! You can still win your case if your policy carries these clauses, but you will need help from an experienced attorney who is knowledgeable about ERISA disability claims.
Give our office a call at 202-393-3320. We want to hear your story, and we're very sorry that your claim has been denied unjustly. Even if you don't need to hire an attorney, we will educate you about your situation and point you in the right direction. But don't wait - these cases have strict time limits to take action, so do it today.