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June 2012 Archives

Is Your Insurance Benefits Claim Governed by ERISA?

ERISA stands for the Employee Retirement Income Security Act which was passed by Congress and signed into law by President Ford in 1974. When the Employee Retirement Income Security Act ("ERISA") became law, it was codified as a part of Title 29 of the United States Code, and is found in multiple sections beginning with Section 1001. Essentially, the Employee Retirement Income Security Act is a federal law that supersedes state laws and regulates employee benefit plans and determines the rights of beneficiaries under those plans. This includes disability, life, health or long-term care insurance benefits that are provided to employees as a benefit of their employment by employers. The statute defines an "employee welfare benefit plan" as "any plan, fund or program . . . established or maintained by an employer or by an employee organization" which provides employee benefits. An "employee welfare benefit plan" subject to the Employee Retirement Income Security Act is easily created by an employer when establishing a plan to provide group insurance benefits to its employees. In fact, insurance policies and benefits obtained through an employer typically fall under this law.

Disability Insurance Law Group Successfully Overturns Prudential's Termination of Lupus Claimants Disability Insurance Claim

After being approved for disability insurance benefits for almost two years, without warning, Prudential Insurance Company simply terminated a disability insurance claim of a woman suffering from severe and uncontrolled systemic lupus. Financially devastated by the termination of benefits and extremely ill, the claimant was unsure how to proceed. She eventually retained Disability Insurance Law Group, who prepared an administrative appeal and was able to successfully overturn Prudential's termination of benefits.

Fibromyalgia and the Disability Insurance Claims Process

Those suffering from a severe case of Fibromyalgia know that it can cause widespread, debilitating pain, cognitive problems such as memory loss or difficulty with concentration, and overwhelming fatigue. Unfortunately, the cause of fibromyalgia remains unclear and there are no definitive diagnostic tests (such as X-rays or blood tests) that can be used to confirm the diagnosis or its severity. Additionally, because there is little in the way of "objective" evidence to confirm a diagnosis of fibromyalgia, it is often evaluated as a psychiatric condition by many insurance companies (all in the insured's head) and not considered a truly disabling illness. Moreover, insurance companies realize that some people experience only mild symptoms and can work despite their symptoms. However, what many insurance claims examiners fail to recognize is that for some people, the pain is quite severe and often prevents them from doing simple things like going for a walk, household chores, and going to work. If you have fibromyalgia and are unable to work, navigating the disability process can be difficult and frustrating.

Your disability insurance claims examiner is not their friend and the information you provide to them can often be misrepresented and used against you.

Your disability insurance claims examiner is not their friend and the information you provide to them can often be misrepresented and used against you. It is essential to remember that insurance companies have an inherent conflict of interest in that they are responsible for making the decision on whether you are eligible to receive benefits and they are the party responsible for having to pay the benefit if you are approved. Ultimately, insurance companies are for-profit businesses that earn money by denying claims. For this reason, disability insurance claims are highly scrutinized and often fiercely litigated. Claims examiners work for insurance companies and they are trained from the beginning to ask questions in such a way to elicit certain information. No matter how pleasant and caring they seem, they are not there for your benefit. While your claims examiner may actually be sympathetic to your condition, their hands are tied by the insurance company. Each insurance company creates their own rules and procedures which, claims examiners must follow to "investigate" claims. Their work is closely monitored by supervisors, conversations are often recorded, and they are expected to follow protocol. Accordingly, it is essential that you are not caught off guard or lulled into giving answers that can be misconstrued or taken out of context. This is one of the most common insurance company tactics.  Be aware that what you say and how you say it can be used against you and that your claims examiner has been trained to seek out certain responses and to evaluate information provided in a light most favorable to their employer. 

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