Being unable to work is challenging, whether because of a temporary disability or a long-term one. Luckily, you can file for employer-sponsored long-term disability benefits. However, accessing these benefits is often challenging, and even a simple mistake can lead to denial. For this reason, you should discuss your options with an ERISA lawyer near you.
What is ERISA?
Depending on your employer, you may have various benefits available to you. One of those is disability benefits, for when you suffer an injury or illness that leaves you unable to work. You can be out for days, months, or years. ERISA offers federal protection and a path to appeal denials. However, while there are various disability plans available, not all have ERISA protections.ERISA applies to private health plans, pension plans, private long-term and short-term disability plans, and employer disability plans. It regulates the claim process, timeline, and employee rights. If you have an ERISA-covered plan, you will receive a benefits summary that outlines what you are entitled to and if there are any out-of-pocket expenses.
Coverage under ERISA will come down to who purchases the plan, such as a private company or an individual. Some common reasons for denials include the disability insurer claiming that the claimant is not disabled or does not have coverage under the policy. Luckily, if ERISA covers your plan, you can file an appeal and get a second look. If there is no ERISA coverage, a denial can mean the end of your claim.
What ERISA Is Not
If an employer does not contribute to the policy, it is not an ERISA policy, and therefore you do not get the federal protections. You will see this when employees purchase individual policies and contribute outside the employer. It can get confusing because while some employers do not offer these benefits, they allow signage and other displays in the workplace for these plans. If you don’t know your disability benefits under ERISA, speak to your human resources department for clarification. If you are applying for benefits, you should speak with an ERISA lawyer to discuss your options as soon as possible. Regardless of who purchased the policy, certain injuries and illnesses do not have any protection under ERISA. A workplace injury, for example, will be covered under workers’ compensation. However, it can be challenging to tap into either benefit plan as you can suffer a denial. It is best to work with a lawyer who can determine your best option and help you file a claim.Private Versus Public Disability Benefits
Private companies can provide employees with short and long-term disability benefits for qualifying reasons covered under ERISA and a group policy. Church and government workers receive disability benefits but are exempt from ERISA. Government employees have difficulty getting benefits because there is often confusion about what benefits they have access to. Public plans are nearly always exempt from ERISA. While employers have the option to offer these benefits to employees, some states require that employers do. When employers in select states do not offer disability benefits, they will be subject to fines and penalties. Unfortunately, these employee-sponsored plans do not have ERISA protection due to a clause that states ERISA does not apply to plans that are “maintained solely for the purpose of complying with applicable ... disability insurance laws.”ERISA Disability Lawsuits
If you receive a disability denial, file an appeal and obtain another rejection; your next option is to file an ERISA lawsuit with the assistance of an ERISA disability lawyer. You will need to prove the insurance company made an error in denying your benefits, and a judge will review the entire claim and come to a determination. It will be the judge’s discretion whether they overturn the initial decision or agree with it.
Importantly, if you go to court, you cannot submit new evidence. The court will only review the insurance company’s file. All the documents you submitted to the insurer are within the file, including the insurance policy, denials, and appeals information. What you might believe to be insignificant can help your case. Since you do not know the possible outcome of these lawsuits, it is vital to have a long-term disability lawyer guiding you from the beginning since you will not have many chances to submit evidence.
Avoid These Application Mistakes
Applying for disability benefits can be very complicated, and there are some mistakes you must avoid. Unfortunately, certain errors can lead to a denial of benefits, leaving you with nothing. If you do not get the benefits, you may need to dip into your savings or go into debt to cover your expenses. Having a long-term disability can set you back financially for years. The best way to ensure that you avoid these mistakes is to work with an ERISA lawyer from the beginning of your claims.Do not assume your employer’s opinion matters
While your plan is an employer-sponsored program, your employer does not make the final decision about your claim or the payment. Some workers assume that since their employer agrees they are too sick to work, they will have a successful claim. Do not assume that you will receive benefits since the insurance company is the one processing and paying your claim, not your employer. Insurance companies have definitions for disability, and the employer has no say in these definitions.Listening to human resources
While the human resources department is there to guide employees on what to do and how to navigate difficult situations in the workplace, they do not make determinations on insurance claims. They do not interpret or influence insurance policies or procedures and only provide a pathway of options. The rest is up to you.Using only insurance company documents
You should meet with your doctor and ensure you understand your condition and how it affects your employment efforts. You must fill out all insurance company paperwork, but when documenting your injury adequately, you must use other resources. Your doctors, employers, and other parties will all get a version of the documents they must fill out to help your claim. Be cautious, as some physicians will charge for these services, but they are essential to your claim.Going against your doctor’s recommendations
The insurance company does not want to pay disability claims, and they go to great lengths to deny them, including having someone watch you. If your doctor explicitly says you cannot participate in an activity, do not go against their orders. If the insurance company sends someone to watch you and finds you are participating in activities you should not be engaging in, they will paint you out as a cheater and deny your claim. One way to know that the insurance company is watching you is if you receive an activity log from the insurance company.Relying on the insurance company for advice
While you should be able to trust the insurance company, you cannot. Some injured workers make the mistake of relying on the insurance company’s advice regarding other benefits. For example, the insurance company may suggest that you apply for social security disability (SSD) benefits so they can reduce your long-term disability benefits. The best way to ensure that you are maximizing your claim is to work with a lawyer from the beginning.Working with a non-ERISA lawyer
While you must have a lawyer representing your best interests in these claims, you should not hire just any lawyer. You need someone who specializes and has experience with ERISA claims. It is a very complex law, and there are many regulations that you must adhere to. When interviewing lawyers, ensure they have experience in this field and can represent you effectively.Things to remember in LTD claims
Workers’ Compensation benefits are available to workers who suffer an injury or illness in the workplace, leaving them unable to work. Your LTD claim is for disabilities outside the workplace and allows you to recover some of your lost income when you are out of work. It is different from worker’s compensation because the ailment does not need to happen within the scope of employment. While these benefits exist, you need to remember a few things to ensure you do not receive a denial and can access the benefits you need during this difficult time.The definition of disability
Depending on your policyholder, the definition of disability will vary; some will have a vague definition, while others have a stringent one. While they can sound like the same thing, they are very different. Definitions can state that the ailment hinders the person substantially or they cannot perform duties. Additionally, when you exhaust certain benefits after 24 months, the disability definition will go from “own occupation” to “any occupation,” which differentiates whether a person can work within their field or in any employment. It can also mean benefits are exhausted and terminated after 24 months if you do not qualify under the “any occupation” standard.There is a waiting period
There is a longer waiting period for long-term disability benefits than for short-term disability benefits. Typically the waiting period is 90 to 180 days before the insurance company can deem you eligible to obtain benefits. Luckily, if you have a short-term disability, the waiting period is not as stringent. Once those benefits run out, then the long-term ones can begin. It is meant to be a seamless system, but it does not always work out that way.Long-term disability is taxable
Determining whether you have an individual or a group policy will be instrumental in whether your benefits are taxable. Group plans are taxable, while individual plans are not. Employers pay these policies with pre-tax dollars; individual plans are paid with after-tax dollars, so those are not taxable. Reviewing your policy and asking your LTD lawyer what to expect is best.They are watching you
Hiring a private investigator is not out of character for insurance companies. They want to save money and do not save when they pay out long-term disability claims for two or more years. They may send a private investigator to watch you outside your home, work, and anywhere else you frequent. You will not be aware of their presence, and they are looking for even the smallest action they can use to deny your claim.You only receive a percentage of your salary
You do not receive your entire salary under an STD or LTD claim. How much you receive will vary, but you will get a percentage of what you make while working. You should check your benefit summary packet or speak with your human resources representative.For life or years
Your benefits summary page is vital because it will also detail how long you will receive benefits. Some plans offer benefits until retirement, while others use a fixed number of years. Since you cannot work, knowing how long you can obtain benefits is essential.Be sure to document issues related to mental and nervous issues
There will be a limited time that you will receive benefits varying on your conditions and policy. Typically, it is easier to get long-term disability benefits for physical conditions than for mental and nervous conditions. The best way to protect your rights is to ensure your condition is fully documented by every medical professional you see.You Always Need an ERISA Lawyer
J. Price McNamara
Attorney
Losing my own brother, then my father and sister after long, disabling illnesses just a few months apart drove a career change for me. Before that experience, I never truly understood the place you’re in. I never understood the dramatic impact that receiving (or not receiving) the disability and life insurance benefits you paid for and counted on can have on your life especially when you need to focus on family and healing. What I experienced with my own family now drives the way I view my clients and my work, and I will never forget it!
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