What's The Difference Between ERISA Long Term Disability Insurance and Non-ERISA Plans (ERISA Exceptions) and Why Do I Care?
After being seriously injured as the result of an accident or coming down with a serious illness that leaves you out of work, navigating the complexities of filing for long term disability insurance is a difficult and taxing undertaking, on top of the fact that you are dealing with the medical system - surgeries, rehab, doctor's appointments, therapy, specialists. To help clear up some of the confusion, we like to educate people on what it means to have an ERISA long term disability policy along with a few frequently asked questions about ERISA and long term disability insurance claims.
What is ERISA Long Term Disability Insurance? ERISA is a federal law called formally called the Employee Retirement Income Security Act. Long term disability insurance policies that are provided by private insurance companies as a benefit to private sector employees are regulated by ERISA. If you have a long term disability policy through your place of work and you are not a government employee, it’s likely that your policy is governed by ERISA.
Your long term disability policy will say that, and if your claim was denied or your long term disability benefits terminated, the letter denying your claim should say that as well.
My long term disability insurance plan falls under ERISA. What does that mean for me? You have a long term disability insurance policy that is governed by ERISA. Great! Here’s what you should know: ERISA is meant to protect consumers and claimants who need the benefits of a long term disability insurance plan, however it also provides a lot of ways for insurance companies to deny your claim. This is because ERISA law gives far more discretion on claims to insurance companies than it should have.
Claims that are made on an ERISA governed long term disability policy are special in that, if a claim is denied, you must first appeal to the disability insurance company - the one that just denied your claim. And that appeal is critical - it is your only opportunity to formulate the evidence you will need to have your benefits reinstated.
If your appeal is denied, you must file a lawsuit in federal court (ERISA is a federal law). A federal judge, not a jury of your peers, will decide whether the insurance company's decision to deny or terminate your long term disability benefits was "reasonable."
And there is no discovery in these cases. Discovery is a period of time that allows both sides of the claim (you and your attorney) to gather documents and put together a case. In discovery, the other side of the claim, namely the insurance company, would then gather evidence to defend their right to deny your claim. In ERISA, there is no opportunity for discovery and your entire case rests on what's called the "administrative record." That's the technical term for your appeal - everything you put into it.
What you don't know is that the insurance company has been gathering evidence to use against you if necessary, since the day you filed your claim for long term disability benefits. And if your claim is denied, you only have 180 days to appeal. That's 180 days to put together an administrative record for yourself that a federal judge will use to decide your case. Are you ready, willing and able to do that?
One of the best ways you can help your claim for long term disability be approved is to hire an attorney who has the knowledge to handle long term disability claims. Only an experienced attorney will know how to put together a comprehensive and persuasive administrative record that will support your claim and put you in the best position to win your appeal.
What else should I know about ERISA policies before filing a claim? A few of the most important things to know about ERISA polices are as follows:
Different insurance policies have different definitions of what constitutes a disability. It’s important to understand your particular policy or have someone on your side who can understand your policy and act on your behalf. There are a few deadly clauses in standard long term disability insurance plans that indicate your insurance company will have the discretion to deny your claim on its face. You should know whether or not your policy has them included. Chances are, if it's an ERISA policy, it does.
Most policies have a waiting period between the time you became disabled and when you become eligible to receive long term disability benefits. If you are currently on short term disability, you should have your long term disability insurance plan reviewed to watch out for those deadly "discretionary" clauses.
If your claim has been denied, send us a copy of your denial letter immediately, and will review it for free and help you get started. That denial letter is critical, so call us and email it to [email protected], or fax it to 202-393-3324 or just drop it off at 1901 Pennsylvania Avenue NW, Suite 900 Washington, DC 20006.
The insurance company has every reason to find a reason to deny your claim. For this reason, it’s important that all aspects of your claim be correct, consistent, and put together in such a way that limits the ability of your insurance company to win a denied disability appeal. The insurance company has lot of legal talent on their side. Why should you not have the same?
Having an attorney on your side is one of the best things you can do to help your long term disability claim be approved. If you would like to speak to someone about your long term disability claim, reach out to us today at 202-393-3320.