Get Help Now From an Experienced ERISA Lawyer
Disability insurance is supposed to be there to protect you when you are injured or ill and can no longer work. Many people are surprised that the reality does not match the promises they received when they try to file a claim. Instead, they get the runaround from companies like Guardian, which wrongfully deny their claims or cut off their benefits.
The law gives you rights as a claimant, and a disability insurance attorney can help you fight the denial.
Guardian Collects Premiums for Short and Long-Term Disability Plans
Guardian sells its disability insurance as a way to protect your income. They emphasize the fact that you can be covered when you cannot earn an income. What they really protect is their own bottom line.
Guardian offers two types of disability insurance to customers:
- Short-term policies that cover people for up to one year when they cannot work due to injury or illness (some short-term coverage options extend for longer than one year)
- Long-term policies that offer coverage for a period between two years and the policyholder’s retirement age
The company sells its services by telling potential customers that one in every eight people will suffer one or more disabilities throughout their lifetime, with a condition that keeps them from working for five years or more. The company takes in billions of dollars in premiums annually.
Being Part of Berkshire Hathaway Does Not Give Policyholders Much Comfort
Guardian is a subsidiary of Warren Buffett’s Berkshire Hathaway. One might think that being associated with the legendary investor with a reputation for doing things right will set it apart from other insurance companies in the way that it operates. Unfortunately, the reality is far different. Guardian is the same as every other insurance company in how they handle and treat claims.
Guardian Faced Serious Trouble for its Past LTD Business Practices
Guardian’s business practices have historically been so bad that the State of New York had to pass a law to restrict some of what they do. A company memo referred to an insurance policy for a muscular dystrophy patient as a “dog” and “trainwreck” as Guardian tried to cancel his policy.
This means that the company may be no better when you try to apply for the disability coverage that your plan promises you. Even when you have had benefits approved, Guardian has a pattern of terminating coverage, forcing policyholders to fight in court. It is never an easy process when dealing with this company.
You Have Legal Options if Guardian Denies Your Claim
Your legal remedies for a claim denial depend on how you have your coverage through Guardian. If your coverage is through an employer-purchased group disability policy, a federal law called ERISA governs your rights. While it is not the most claimant-friendly law, it does provide you with the right to appeal the denial.
If you privately purchased your own disability insurance coverage from an agent or broker, you will proceed differently to fight the denial. You may even file a lawsuit against Guardian in court, as many denied claimants have done over the years.
Why Guardian May Deny Your Disability Claim
The company makes life hard on claimants. It never misses an opportunity to deny a claim.
Here are some of the reasons that Guardian gives when it denies disability claims:
- They do not believe that your condition meets the policy’s definition of the word “disability.”
- They claim that there is no “objective evidence” of your condition.
- They do not believe that you have a qualifying disability and cannot work.
- They will claim that your claim is missing a required piece of paperwork.
- They will claim (after using video surveillance or people to follow you) that you are not disabled after all.
What Guardian Does to Make Your Life More Difficult
Like any company, Guardian has tactics that it likes to use to make your life harder.
- Ignore your doctor’s opinion in favor of their own in-house doctors who may not even take the time to examine you or who lack the qualifications or expertise to evaluate your condition
- Try to rescind your policy or terminate your benefits based on technicalities
- Making tenuous claims that your diagnosis does not support your claim
Guardian may even try to argue that your disability is due to a pre-existing condition that you had before you bought the policy, even after you have clearly suffered an injury (this claim came from a real case). In other cases, they have terminated benefits, even after the claimant’s condition did not improve at all.
Guardian Is Like Any Other Insurance Company No Matter What it Says
Guardian tries to portray itself as your protector and friend, at least until you sign on the dotted line and pay for the policy. After that, it becomes like any other insurance company when you try to make a claim.
Guardian does not get the final say about whether you can receive disability benefits, even if they deny your claim. The law gives you rights and remedies to have your benefits denial reviewed by several people before the decision really is final.
You Have Legal Rights Under ERISA
ERISA gives you rights when you have a group disability policy through work because it is an employment benefit. However, you must follow the process exactly to get a meaningful review, including the timeframe that you have for an appeal.
Under ERISA, the first level of review is the insurance company itself. This is where the appeals process begins. You may wonder how it is fair that the company that denied your claim gets to decide whether it was wrong. You may have serious questions about the objectivity of this review. Nonetheless, you must fully participate in this part of the process if you want the denial reviewed.
Guardian Must Tell You Why They Deny Your Claim
Before you file an appeal, you will understand exactly why the insurance company denied your claim. After recent changes to federal regulations, they must give the reason for denial and share with you any documents that they reviewed in making this decision. They must also have a different person handle your appeal than who made the initial denial decision.
If you do not have an attorney yet, you need one before you begin the appeal. While it is not a legal requirement, you need to have someone who has experience with the process. The stakes are too high to try to go it alone. Your Guardian disability attorney can have an initial conversation with the insurance company to see if they can resolve your claim without the need for an appeal. If not, they can help you build the necessary record for your appeal.
Building an Administrative Record for Your Benefits Appeal
We mention the record because this is what will be the basis for decisions throughout the appeal process. Under ERISA, the rule is that you cannot add information to the record after the initial appeal to the insurance company.
The administrative record in your ERISA appeal should consist of:
- All information that you presented to the insurance company to support your claim
- Medical records
- Opinions of physicians to support the finding of disability
- Job descriptions
- A copy of your policy
- Any documents that the insurance company created during the review of your claim
- Relevant employment information
Taking Your Case to Federal Court
It is crucial to build your medical case now. If your appeal is unsuccessful, you will need to proceed next to the federal district court. Here, you will not be allowed to add more information to the administrative record unless there is an exception and the judge specifically asks for it. Otherwise, you can assume that the administrative record closes at the insurance company phase of the appeal.
You do have the legal right to proceed to federal court, allowing you an objective review of your appeal that Guardian does not conduct itself. However, you will not have a hearing or have the opportunity to testify in front of a judge or jury. The judge will consider the administrative record in making their determination of whether you can receive benefits. If you are unsuccessful in district court, you can go to an appeals court, where the judges will decide whether the district court judge made a mistake in denying your appeal.
There Is a Different Process for Private Disability Plans
Different rules apply when Guardian denies your claim on a private disability policy. Here, ERISA will not apply since that law only governs disability policies provided as part of your job. In this case, you have arguably greater rights to appeal the denial that allow you freer access to the courts. You have a much greater ability to obtain evidence and introduce it for your appeal.
Unlike ERISA claims, you can also sue Guardian for a bad faith denial of your claim. In addition, you can get your case in court in front of a jury. In this situation, state law will govern your case instead of ERISA. Guardian has a duty of good faith, and their often flimsy reasons for denying claims can run afoul of these laws. You will have your day in court in front of a jury if Guardian has violated its contractual obligation to provide you with benefits.
Private Plans May Give You the Ability to Sue for a Bad Faith Denial
Here is what the law might consider bad faith when Guardian denied your private disability insurance claim:
- Imposing unreasonable documentation requirements that your policy does not mandate
- Not responding to your claim within a reasonable amount of time
- Rejecting your claim for a completely invalid basis
- Trying to give you less in benefits than your plan requires
- Using intrusive or unreasonable investigation methods
- Harassing you or being unreasonably demanding during the claims process
Unfortunately, these are tactics that insurance companies like Guardian use to make it tougher to get benefits. Whenever they need to pay a claim, it means that they must take premiums (that they invest in the stock market to earn money for them) and use those funds to issue benefits to claimants. This is something that they do not like doing. Their promises of protecting you only last so long until you try to hold them to their promise.
What a Guardian Disability Attorney Can Do for You
The most important thing when Guardian has done you wrong is to hire an experienced disability benefits lawyer. There are many reasons why you need an attorney in your short-term or long-term disability case.
Here are some:
- Guardian may take you more seriously when you have an experienced attorney fighting for you.
- An attorney is familiar with the technical process for ERISA appeals.
- A lawyer will know how to build the strongest administrative record in your case.
- Your attorney will know when Guardian is not following the rules under ERISA (recent changes to federal regulations allow you to sue if the insurance company does not follow the required process).
- You will know that you have someone experienced working on your behalf, giving you some peace of mind.
Be Prepared and Hire an Attorney as Soon as Possible
You may want to consider hiring an attorney before you even file your claim. The attorney can prepare a persuasive claim. They know why companies like Guardian deny claims, and they can help you avoid some common traps that claimants fall into that can make their life tougher.
Even more important, you need an attorney who understands how these companies operate through actual experience working against these companies. An ERISA attorney has the knowledge to defeat insurance companies because they know the games that they play.
A knowledgeable disability attorney can help convert the denial to an approval, whether the insurance company likes it or not. Having your claim denied is not the end of the story—if you involve an experienced ERISA lawyer in your case.
Following graduation from Loyola Law School in New Orleans in 1990, Price McNamara served as a Federal Judicial Law Clerk to the Honorable John M Shaw, Chief Judge, United States District Court Western District of Louisiana.
Mr. McNamara founded the Law Offices of J. Price McNamara, and began putting his past experience to work for the injured and disabled clients he now represents against the insurance companies in personal injury and long term disability and other insurance disputes in both federal and state courts