You've got a serious illness, your doctor says you're disabled, you can't work - isn't that enough to win your ERISA disability case?
It's a good start - but no guarantee, that's for sure. Here's why: when your ERISA disability claim gets to federal court (that's where you file after your appeal is denied) there are usually 2 possible standards of review for the judge that tells him or her the standard for judging your case - remember, there is no jury trial or jury to convince in these cases.
The two standards are "abuse of discretion" and “de novo” - and the de novo standard of review is what you want. This means “starting anew,” so that the federal judge is taking a fresh look at the evidence in your case and usually going back to the question of whether your disability (your illness or injury that prevents you from working) mean you qualify you for disability benefits under your insurance plan.
Under the de novo standard of review, you still have to prove more than just the fact that you are disabled, you'll also have to prove that you qualify for disability benefits, you meet the terms and definitions under your specific disability insurance plan. That's a bit more of a common sense type standard - what you would expect they have to prove in other words.
The “abuse of discretion” standard of review is what makes so many ERISA disability cases (and probably yours) so difficult. The abuse of discretion standard means that the court is NOT ruling on whether you are disabled and qualify for benefits.
Instead, the federal judge will just decide whether the insurance company’s process for arriving at their decision to deny your benefits was reasonable. That's it. What does reasonable mean? Well, as you probably know, it could mean just about anything. Under an abuse of discretion standard, the judge can agree with you that you are disabled, can't work and are covered under the insurance disability policy - that's all great.
But even with those findings, if the disabiity insurance company is able to justify their decision, the insurance company wins.
This really difficult standard of review is triggered by a clause that nearly every insurance company tries to put into their employer-offered disability policies. It's called a discretionary clause and it says something like : “We reserve the discretion to determine benefits under the policy.” It applies to every person covered by the disability policy. It gives the insurance company a lot of room to justify their decision to a judge.
If you have questions about ERISA long-term disability cases, call us at (202) 393 - 3320 and if your claim has been denied (you received a denial letter) and you would like to have your denial letter reviewed for free, call us to get started. But don't wait, once you get that denial letter, the clock is ticking on your appeal.