ERISA Disability Claims

ERISA Law Provisions in Your Long Term Disability Policy

Published on September 5, 2014 by

I began this series on understanding your long term disability policy by saying that it’s not as simple as merely paying your premium and filling out the application after you start suffering from problems. Every policy has specific requirements that you have to meet in order to qualify for benefits, and so far we’ve covered some of the most common provisions.

After detailing the definition of disability in the first part of the series and covering elimination periods, earnings caps, and more in part two, today the focus is going to be on policy limitations and appeals issues.

Understanding Policy Limitations and Appeals Procedures

Mental health benefits. One of the most common uncovered areas is “mental health conditions.” If you have a disability that is caused solely by a mental health issue such as depression, your insurer may limit your benefits to a time defined within the policy, often 12 or 24 months. It’s worth exploring your condition more fully, though, because certain mental health problems like dementia or other brain diseases will still be covered on a long term basis.

Pre-existing conditions. One of the big changes going forward because of the Affordable Care Act is that insurers have to cover you for problems that you had before signing up with them. However, even last year most insurers included clauses stating that they would not pay for pre-existing conditions and had the ability to look into your medical history if you filed a long term disability claim for something within a set time after becoming insured, such as one year. Because of this long-standing provision, many claimants are still fighting their insurers for past benefits they believe they should receive.

Appealing correctly. Sometimes, even though you know that you should receive long term disability benefits, your insurer will deny your claim. That doesn’t mean you should give up – there’s an appeals process in place for a reason! But you need to make sure you work with an experienced disability attorney and follow the appeals procedures closely or you can lose your eligibility if you make a mistake. One common rule is that you have to file your appeal within a set timeline after you’ve been denied, but many policies have others, and most in this country fall under ERISA law, which has its own set of appeals requirements.

Keep checking our site for more long term disability news and updates. Be sure to download a copy of our free e-book and check back weekly for new blogs that will keep you up to date on long term disability issues!

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How is The Term Disabled Defined in Your Long Term Disability Policy?

Published on August 20, 2014 by

If you know that you have long term disability benefits as part of your insurance policy, you might think that getting those benefits is as simple as completing an application. Unfortunately, as part of an experienced long term disability law firm, I can tell you that is decidedly not the case.

There are specific terms that you have to meet in order to qualify, and those terms differ depending on the policy itself. However, there are a number of provisions that are typical to most long term disability policies. Today, we’re going to cover one of those provisions – meeting your insurer’s definition of disability.

You’ll Only Receive Long Term Disability if You Meet the Included Definition

If you look through your policy, you will see a definition for Disability or Total Disability. Frequently, these are broken into two parts – the first describing disability as an illness or injury that keeps you from doing your own occupation, and the second part saying that this same condition doesn’t allow you to work in any occupation. Generally speaking, the second part doesn’t really come into play until after 24 months. Someone suffering from the same ongoing disability that is preventing them from obtaining gainful employment should qualify for this second part, which is essentially just saying that you’re not able to work at all, regardless of the job.

Pay careful attention to the words used in this definition. Often your insurer will provide definitions for those, too, and you have to meet every part of the definition to qualify. Some common ones to watch out for include:

Own occupation. This refers to the job that you currently hold or held before your disability interfered. If you’re an accountant, you have to be able to show that your condition prevents you from doing that kind of work to meet the “own occupation” clause.

Any occupation. The word “any” tends to throw people off here, because it doesn’t literally mean that your disability keeps you from doing anything at all. Under most definitions, it means that you can’t do any job for which you have training and experience. A trained lawyer, for example, probably has experience that would allow them to work in a number of other fields, but a construction worker’s experience could limit them to physical labor.

Injury or illness. Many insurers refuse to pay disability if the injury you’re suffering from was self-inflicted or your illness involves drugs or alcohol. And these are only two of the most common conditions excluded. Look carefully at your policy to make sure your disability is covered.

Next time, we’ll talk about another provision you need to meet to quality for long term disability in ERISA plans – the elimination period.

If you’d like to learn more about long term disability in general, check out our free resources!

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What to Know about the ERISA Administrative Appeal Procedure

Published on July 18, 2014 by

Filing an ERISA claim and receiving benefits is not an overnight process, and the ERISA administrative appeal procedure alone can take up to a year. Here’s what anyone filing an ERISA claim should know about the administrative appeal process and the statute of limitations.

Under federal law, a claimant cannot bring a claim under judicial review until an internal review is carried out. This internal review, or presuit administrative appeals procedure, begins when a claimant submits their proof of loss. At that point, the Plan has a set amount of time to carry out an internal review before the claim is taken to a judicial court. How does this work?

  • The Plan has 45 days to make adverse benefit determination (i.e. to determine that benefits are not a medical necessity to the claimant or that the claimant is not eligible for benefits for any other reason).
  • The Plan may use two 30 day extensions based on elements outside of their control, such as a claimant’s failure to submit documents necessary to make a decision based on their claim.
  • The claimant must appeal a denial of their claim within 180 days of that denial.
  • The Plan has 45 days to resolve any appeal with one 45 day extension.

The Statute of Limitations for Civil Action

Claimants need to pay close attention to the timeline for filing a lawsuit, because the statute of limitations for civil actions in ERISA cases has recently changed. As I mentioned before, statute 502 (a)(1)(b) requires that a claimant exhaust the internal review process before bringing their case under judicial review. ERISA does not provide a statute of limitations for actions under 502 (a)(1)(b), but a specific ERISA plan may have a limitation provision that goes into effect as soon as an individual files their claim.

Previously, the Supreme Court has been divided on whether an ERISA plan limitation provision is enforceable during the internal review process. Since the internal review process can take a year or more, it may use up a substantial amount of the claimant’s limited time to file a lawsuit. In 2013, the Supreme Court resolved this issue by ruling that a three year contractual limitation on an ERISA plan is enforceable, and the three year statute of limitations is measured from the time an individual files their claim (including the internal review process).

Claimants who are worried that the Plan is dragging out the ERISA administrative appeal procedure or otherwise trying to stop them from filing a lawsuit within the three year period should meet with an experienced ERISA attorney as soon as possible or read our free eBook to learn more.

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What to Do If You’re Told Your Disability Insurance Is ERISA

Published on May 23, 2014 by

There’s an unfortunate trend happening right now where companies that offer disability insurance are suddenly telling policyholders that their plan is governed by the Employees Retirement Income Security Act when they file a claim – even though this fact was never mentioned anywhere before then!

Why’s this going on? Because insurers know that they’re far more protected from legal liability under the Employee Retirement Act than they would be if the plan in question was independent. This has led them to attempt to retroactively alter plans so that they are covered under the federal rule, and sometimes even bend the truth or outright lie to people when they make a long term disability claim.

Luckily, there are ways that a policyholder can determine whether or not their plan really is under these far more insurer-friendly regulations, but you’re going to have to look into the matter yourself if you want to appeal a denial.

When Your Insurance Policy Isn’t an ERISA Policy

How can you prove that your policy isn’t what they say it is? Check the facts.

Was it sold to you as an individual policy? By definition, the Employee Retirement Income Security Act covers group policies. If you purchased your policy individually – even if an employer pays for it – that does not mean that it’s covered under the federal act.

Can you switch jobs and keep your insurance? If it’s possible for you to leave your current job and still maintain your current insurance policy, then there’s no way that it falls under federal regulations.

Are you the individual owner of a personal corporation? The Employee Retirement Act clearly doesn’t govern plans for these types of individuals, but that won’t stop insurers for trying to classify your policy in whatever way benefits them most.

Experienced disability attorneys can show you not only what to look for, but also how and where to find that information and what to do with it.

Check out our free disability eBook to learn more about different policies and how you can fight for the benefits that you need.

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