ERISA FAQs

By the attorneys of Disability Insurance Law Group

The following information is provided in order to help you understand some of the general concepts and common concerns that arise in relation to an ERISA claim. For specific answers from an experienced ERISA lawyer, please contact the Florida offices of Disability Insurance Law Group to schedule a free consultation. We serve clients nationwide.

Q: What information do I need to provide with my application for disability insurance benefits?

A: You have an obligation to provide sufficient information regarding your condition, limitations, and restrictions. You must also submit information regarding your occupational duties. It is essential that your treating physicians understand the importance of documenting your disabling symptoms and how your condition limits your abilities. It is also necessary to clearly and thoroughly outline your occupational duties. You should not rely on a generic occupational duties list from your employer. Such documents rarely address all of the necessary functions of your occupation. Your insurance carrier typically does not indicate exactly what information is needed to prove your claim. Instead, many insurance companies simply request that you complete a Claimant's Statement and your physicians complete an Attending Physician's Statement and provide medical documentation. Claimant's often reasonably rely on the insurance carrier's statements and only submit the documentation requested. Many claims are denied simply because of a lack of sufficient information, despite complying with all their insurance carrier's requests.

Often treating physicians simply do not understand the definition of Disability contained in the policy. Most policies define Total Disability (at least for a limited period of time) as the inability to perform the material duties of the claimant's occupation. Accordingly, a claimant does not have to be completely incapacitated to be disabled under the policy. Without understanding the definition of disability and the claimant's occupational duties, treating physicians are often unable to properly complete the insurance companies' forms. Often insurance companies will contact a claimant's treating physician and request that he or she provide an assessment of the patient's ability to return to work. Many times the insurance companies will provide a very limited assessment of a claimant's occupation, terming it as sedentary or light duty, without explaining the actual requirements. The insurance companies will typically not inform the physician that he or she should account for whether the claimant can actually work with reasonable continuity, would require unrealistic accommodations, or if the claimant's medications causing disabling side effects.

We typically consult with our clients' treating physicians, provide them with a truly representative occupational duties list, and explain the definition of Total Disability. This allows them to make a fair evaluation of our clients' ability to work in their occupations. We also explain that the physician must make a full assessment of the claimant's condition, such as whether the claimant would require a significant amount of sick leave and thus, would be unable to work with reasonable continuity or would have severe limitations due to side effects from medications. Insurance companies often request that a claimant's treating physician complete an Attending Physician Statement that typically does not allow for a full explanation of the claimant's limitations. We provide our clients' treating physicians with our own Attending Physician Statements that allows for a full and fair evaluation of our clients' disability and limitations. These forms are created specifically for each client, based on their disability and their particular policy terms.

An application for disability insurance should never be taken lightly. You are required to give specific information to prove your claim. Insurance companies do not make this easy or inform you of the information needed to prove your claim. This lack of knowledge often allows for insurance carriers to deny benefits to truly disabled and deserving claimants. Understanding both your rights and obligations under your policy is essential to proving your claim.

Q: How severe does my disability have to be in order to qualify for disability insurance benefits under my policy?

A: Under many group policies for a limited period of time (typically 24 months), your condition must prevent you from performing the substantial and material duties of your regular occupation. This is called the Own Occupation Period. Under such policies, you are not required to be completely incapacitated or unable to work in any occupation. Your condition must simply interfere with your ability to perform your job.

Following this limited Own Occupation Period, many group policies have a change in the definition of total disability to the inability to perform the material duties of any occupation. However, your insurance carrier usually must take into consideration your education, training, and experience, as well as the availability of the alternative occupations in your local economy. Occasionally, the policy requires insurance companies to also consider the claimant's pre-disability income. Many insurance carriers ignore such factors and simply deny claims after the change in definition.

Under many of these same policies, if you are able to work in your occupation in a limited capacity, rendering you partially disabled, as opposed to totally disabled, then you may collect a portion of your monthly benefit.

Q: Do I have to submit to an independent medical examination?

A: Typically, Yes. However, this depends on what stage of the process the request is made and the insurance company's right is not unlimited. In most group policies there is a requirement that you must submit to an independent medical examination when the insurance company is assessing your application for benefits or your right to continued benefits. Also, you are required to provide sufficient proof of your condition, and many insurance carriers will deny a claim based on a refusal to submit to such an examination. However, if your claim has been denied and you have only one level of appeal, your insurance company is not free to require an Independent Medical Examination ("IME") to bolster its denial.

Moreover, it is essential that the evaluation requested by your insurance carrier is actually relevant to your condition, the appropriate specialist is chosen, and the request does not unreasonably burden you. Moreover, it is important to remember that your insurance carrier has chosen and paid the medical examiner. An independent medical examination that is not truly independent can be extremely detrimental to your claim. For this reason, we often request that such evaluations are videotaped and assert our clients' right to an examination by a physician appropriate for their particular conditions. We also often run background checks of the medical examiners chosen by the insurance companies to determine their actual independence.

Q: What are my options and obligations if my insurance company denies my claim?

A: Most group disability income policies provided or bought by individuals through their employment, are governed by the Federal Statute, the Employees Retirement Income Security Act of 1974 ("ERISA"). Under ERISA, claimants are required to appeal a denial of disability insurance benefits directly to the insurance carrier that denied the original claim. Under some policies, there are two or three rounds of appeal. However, typically you are only required to submit one appeal. It is essential that you submit all mandatory appeals prior to filing a lawsuit. Under most claims, you have 180 days to complete your appeal. Six months may sound like a long period of time however, with the amount of information that is typically required to create a successful appeal; it is essential that you do not take this process lightly or waist any time in gathering the necessary information to present with your appeal.

In a private or non-ERISA disability insurance claim, if your insurance carrier wrongfully denies your claim, you can file a lawsuit and begin to gather all of the evidence you need to prove your case at trial. This includes obtaining all of your medical documentation, eliciting testimony from your family members, friends, and co-workers that have knowledge of your condition, and obtaining independent medical and vocational expert opinions. This process can often take up to two years to effectively prepare your lawsuit. However, in an ERISA claim, you must prepare your lawsuit in only six months. This is because, in most ERISA claims if you fail to provide any information to your insurance carrier in your appeal, you are forever barred from presenting it during your lawsuit. Essentially, you must prepare your lawsuit before filing suit. Most insurance carriers simply do not explain this fact; encouraging claimants to prepare wholly insufficient appeals in a rush to overturn a wrongful denial and ultimately barring claimants from being able to prove their claims at trial. Most claimants would not choose to prepare for or go to trial without the aid of an attorney however, many claimants simply do not understand that by submitting an ERISA appeal without consulting an attorney with experience in ERISA disability claims, they are basically doing just that.

It is also important to remember that your insurance carrier does understand the ERISA disability insurance process and thus, often utilizes medical and vocational experts to prepare their claim. For this reason, we painstakingly gather all the information typically required to present at a trial during the appeals process including eliciting testimony from our clients, their employers, friends, and relatives, obtain all the medical documentation relevant to our clients' claims, and acquire the testimony of independent medical and vocational experts. It is also important to be careful not to hastily send in information to your insurance carrier as it may be treated as your final appeal.

If your disability insurance carrier continues to wrongfully deny or delay the payment of your claim, only then can you file a lawsuit. However, typically the only information that you are able to present at trial is the information gathered during the application and appeals stages. A well documented appeal is essential to a successful result at trial.

Q: How do I know if my claim falls under the Employee Retirement Income Security Act of 1974 ("ERISA")?

A: Not all group disability insurance policies are governed by ERISA. Typically, policies obtained through an employer fall under ERISA, but there are exceptions. For instance, if you work for a government or religious entity your claim may be exempt from ERISA.

Even if your policy is not governed by ERISA, your insurance carrier will often assert that it is governed by ERISA in its correspondences. Thus, you cannot rely on your insurance carrier alone to provide the necessary information. However, it is highly recommended that you consult with a professional versed in ERISA law before determining that your claim does not fall under ERISA. This is because failing to abide by ERISA deadlines could result in either limiting your ability to provide additional information to prove your claim or restricting your ability to sustain a lawsuit if you fail to submit a timely appeal. Moreover, many ERISA exempt policies contain similar guidelines and deadlines as provided by ERISA and its regulations. Therefore, failure to abide by the policies provisions may have similar detrimental consequences.

Q: What information is my insurance carrier required to provide to me after it has denied my claim?

A: After a claim denial, your insurance carrier is required to provide you with all relevant information to your claim, upon your written request. This includes internal correspondences, telephone call transcripts, expert reports, internal guidelines and much, much more. Unfortunately, insurance carriers do not always provide all the information relevant to your claim. In fact, on many occasions we have found that there was a vast difference between the amount of information that the insurance carriers provided our clients prior to retaining us and what the insurance carriers provided our office upon a subsequent request directly from us. Often this "missing information" proved essential in overturning the denial of benefits. For this reason, we find it necessary to provide an extremely detailed request for information; outlining exactly what information we are seeking.

Other Issues To Discuss With An Attorney at Disability Insurance Law Group

  • When should I file my claim?
  • What information should my treating physicians provide my insurance carrier?
  • What is the difference between total disability and partial disability?
  • Should I submit to a field interview with my disability insurance carrier?
  • How much and what information should I provide my disability insurance carrier
  • How long do I have to wait for a decision on my claim?
  • Do I have to apply for Social Security benefits under my policy?
  • Can I collect Social Security benefits or workman's compensation while collecting disability insurance benefits under my policy?
  • In the event that my claim and appeal are denied by my insurance carrier how does the litigation process work?
  • How are attorney's fees charged?
  • Should I obtain an independent medical assessment from a specialist in my particular condition?

Your initial consultation with an experienced ERISA lawyer at Disability Insurance Law Group will be informative and absolutely free. Our Florida offices serve clients nationwide. Contact us today to schedule an appointment.