Group/ERISA Benefit Plans

By the attorneys of Disability Insurance Law Group

Contents:

Summary of Group/ERISA Disability Benefits

Your bills do not stop, just because you are unable to work. This is the reason that many people opt for disability coverage through their employment. In fact, many people chose their jobs, based on the benefits package offered. The question is, will your insurance carrier or benefits administrator abide by the policy terms and pay your claim? Understanding your rights and obligations when filing a claim can mean the difference between obtaining the benefits you deserve and fatally destroying your claim.

Disability insurance policies and employee benefit plans are often written with ambiguous and confusing contract language. This provides insurance companies and benefits administrators with the ammunition needed to deny and delay claims. Understanding your benefit plan and insurance policy terms and common denial tactics goes a long way in insuring a successful claim for benefits. Most group policies that you obtain as a result of your employment are governed by the Employee Retirement Income Security Act of 1974 ("ERISA").

What Is ERISA?

ERISA is a federal statute that provides extremely strict deadlines and guidelines for claimants and insurance companies to abide by in the processing of a claim, submission of an appeal, and ultimately the determination of eligibility for benefits under a disability insurance policy.

ERISA creates an unequal claims process, placing strict obligations on individuals pursuing benefits that make maneuvering a claim difficult and frustrating for unaware claimants at a time when they should be focusing on their recovery. For most, the process is mysterious and often confusing. What you do not know and what your insurance carrier will not tell you can be fatal to your claim.

If you are applying for benefits under an ERISA governed Plan, you should be aware of your obligations in proving your claim and the strict deadlines you are working under.

When a claim for disability benefits governed by ERISA is denied, the claimant MUST submit an administrative appeal directly to the insurance company that originally denied the claim. If you do not, you may be barred from further pursuing your claim. If your insurance company upholds its denial of your claim following the submission of all mandatory appeals, you may then file a lawsuit.

What most people do not understand is that typically the only information that you may present at trial is the information gathered during the application and appeals process. Accordingly, before you submit any information or respond in any way, you should thoroughly understand your rights and obligations. This is because in submitting an administrative appeal, you are essentially gathering all of the evidence that you will present at trial if your insurance carrier upholds its denial. Most individuals would not think about preparing for and facing their insurance company and its lawyers, without legal counsel. However, in submitting an administrative appeal unprepared, this is exactly what they are doing.

Claimants in ERISA governed disability claims do not have a right to a jury trial. Instead, you must present your case to a single judge. Typically, at trial the goal is not to prove that you are disabled, but that the insurance company acted unreasonably or in its own financial self interest when it made the decision to deny you benefits. As such, ERISA places a much higher burden on claimants in a lawsuit. Moreover, insurance companies understand the burden that claimants are facing and claims examiners are well versed in how to prepare a denial to make it appear reasonable. For this reason, it is essential that claimants put all the necessary information in their applications and appeals.

Navigating the ERISA Process

The attorneys at Disability Insurance Law Group are dedicated to leveling the playing field for our clients. We use our experience in handling these complex legal cases to guide our clients through the process and vigorously fight to protect our clients' rights. When we prepare an appeal, we make sure that all the necessary information is added. Often, this will include expert testimony, independent medical opinions, testimony from co-workers and/or family members, and statements from your treating physicians. The insurance companies understand that we will not hesitate to expend the time and resources necessary to properly prepare our clients' claims and aggressively represent their rights.

If you are unsure of whether your disability benefit plan or insurance policy is ERISA-governed, you should proceed with caution and seek clarification. The laws that govern each type of benefit plan and insurance policy, and your legal rights and obligations under each, are very different.

Let Us Help You

Our attorneys understand the importance of the appeals process and prepare our clients' appeals accordingly. Because of our experience and reputation with insurance companies and benefits administrators, they understand that if an unreasonable denial of benefits is not overturned, we will aggressively pursue our clients' rights in a court of law. They further understand that with a well prepared appeal, we will have the ammunition needed to defend our clients' rights in court.

These cases are highly technical and companies spend millions of dollars per year to scrutinize and defend against these claims. It is essential that you choose an attorney with the knowledge and experience necessary to handle these complex legal issues.

Many denials can be overturned prior to litigation, by effectively preparing an ERISA appeal. However, if a company refuses to overturn its wrongful and unreasonable denial, we will aggressively fight to obtain all benefits owed to our clients in a court of law. The attorneys at Disability Insurance Law Group encourage you to contact us if you are:

  • Planning to file a disability insurance application
  • Have filed and are experiencing a delay in payment
  • Have been denied benefits
  • Having difficulty managing your ongoing benefits claim

Free face-to-face and telephone consultations are available for clients nationwide.