Many of us have some type of long term disability benefit provided by our employer, or maybe you have a private policy you purchased from a company like Unum, Guardian, Reliance, Hartford, etc. It's supposed to protect you if you are seriously injured or have a medical condition and can't work.
You may be looking for information because you have filed a long term disability claim, you may may need to soon, or you have been denied or your benefits stopped.
The reality is, insurance companies can routinely deny legitimate claims - and because of the law governing these cases, most people can't do anything about it (because they just don't know - not because they are incapable or don't have a serious, legit medical condition, they just don't know the system they're in now, one that is specifically set up to allow insurance companies to deny legitimate claims).
We have a lot of information for you here, some basic, some advanced. But if you know you need help now, call us and schedule a time to talk about your specific situation (202) 393 - 3320.
The ERISA Disability Claims Process
First of all, ERISA is a federal law and it stands for “The Employee Retirement Income Security Act of 1974.” This federal law covers a number of different employee benefits, and one of those is private employer disability insurance policies.
There are actually two kinds of disability insurance policies, but only one of them is governed by ERISA. One type is given to state and municipal employees like public school teachers, local police officers, city firefighters, public works and parks and recreation workers. These employees and their disability claims are not covered by ERISA. But private sector employees, people working for defense contractors, hospitals, law firms, medical practices, accounting and financial firms and other businesses generally have disability policies and claims that are governed by ERISA. And as you can imagine, there is an important difference between ERISA and non-ERISA disability policies.
If your disability claim is not covered by ERISA
In a Non-ERISA covered disability claim, the person who is disabled and can't work due to an illness or injury (usually called the claimant) basically has no rights. What does that mean? Well, the insurance policy specifies everything involved in the claim, all of the rules, definitions, terms - everything.
That usually means:
You usually have 45 to 90 days to appeal
There are no standard review timelines
Your appeal has no rules governing how it is reviewed -
the insurance company can pretty much do this how they want to.
If you lose your appeal, you have to file a lawsuit in state court and can get a jury trial
In state court, the case is analyzed under standard contract law rules,
it's really a breach of contract case.
If your disability claim is covered by ERISA:
At least you get some rules, and if you can prove your disability insurance company broke the rules, you have a chance. But - and we can't stress this enough - those rules and the law seriously favors disability insurance companies.
In a disability claim covered by ERISA, here's what you get:
You get a specific, detailed letter or report (or you should) spelling out all the reasons why you have been denied
You have 180 days to appeal the decision - this is not just filling out some form, you probably want to hire a lawyer who understands long-term disability cases. There is a significant amount of work to do to generate all of the evidence and arguments you probably want to include using a step by step process, so 180 days is not a lot of time given the amount of work you are now facing.
The insurance company has 45 days to review your appeal, and can get another 45 days to do the review for “good cause shown.”
If you lose your appeal, you can file suit in U.S. (federal) District Court where a federal judge will decide the case.
The federal judge decides your case based on the briefs you and the disability insurance company lawyers file. The only evidence considered is the record you filed on appeal - you don't testify, neither does your doctor and there is no jury. (Tip: remember this when you are formulating and drafting your appeal to the insurance company - this is a one shot deal).
Your case is decided on whether the insurance company's decision was reasonable based on all of the information it had when it made the decision.
Since it's a federal statute, there is also a lot of federal case law, reported decisions, that governs ERISA disability claims. (for non ERISA disability claims it's hard to say whether this case law would apply). So its important to analyze the ERISA long term disability cases that have come from the U.S. District Court in D.C. and the D.C. Circuit if you were working in D.C. or live in D.C.
Being covered by ERISA is supposed to be a benefit. Unfortunately, It's often more of a benefit for the disability insurance company.
If you have questions about ERISA long-term disability cases, call us at 202-393-3320 to get more information on the process. And especially if your claim was denied - we can review that denial letter for you (for free, no obligation).
But don't wait - if you got a denial letter, that clock is ticking.