Whether you enjoy your occupation or not, everyone takes pride in their ability to work and earn a living. However, what happens when that ability is affected? What if an unexpected injury or illness removes your ability to perform your regular duties at work? When you find yourself in this predicament, you want to ensure nothing compromises your financial situation. One of the types of insurance policies that can provide financial assistance for you to live on is disability insurance.
Disability insurance benefits are not easy to obtain, however. Insurance companies regularly deny these claims for various reasons, leaving disabled individuals without the financial support they deserve. To make matters worse, appealing a denial of a disability claim can be an uphill battle, especially if you have an employer-sponsored policy.
If you received a denial of a disability claim in the Houston area, you want help from J. Price McNamara ERISA Insurance Claim Attorney. We assist with disability claims at all stages of the process, and we have obtained many successful results for our clients. Reach out to discuss your claim denial right away.
Table of Contents
- What is disability insurance?
- What benefits does disability insurance offer workers?
- ERISA (Employee Retirement Income Security Act)
- When are employer-sponsored disability insurance policies covered through ERISA?
- We are not afraid to take on major insurance companies
- Speak to an experienced Houston disability appeal attorney today
What is disability insurance?
Disability insurance is a type of insurance policy that provides disabled workers with partial income to continue to pay their bills. This type of insurance policy benefits many workers, particularly workers who suffer from a medical condition not covered through workers’ compensation insurance.
The two types of disability insurance policies include short-term and long-term coverage.
Short-term disability policies provide coverage for workers who are temporarily disabled, while long-term disability policies cover conditions that permanently disable workers.
What benefits does disability insurance offer workers?
Workers whose ability to perform has been affected by various medical conditions can receive financial benefits through disability insurance. Workers who will not receive monetary compensation through other employer-sponsored policies like workers' compensation can qualify for disability benefits for their conditions. Disability insurance may cover include back pain, pregnancy, mental health disorders, and heart-related conditions.
ERISA (Employee Retirement Income Security Act)
The Employee Retirement Income Security Act, also known as ERISA, is a federal law that helps protect the employer-sponsored retirement plans of employees. Some of the plans covered through this federal act include benefit plans like flexible spending accounts, life insurance, and disability insurance. ERISA informs workers of their rights and how to exercise them. Through this act, workers have the right to sue for their benefits.
When are employer-sponsored disability insurance policies covered through ERISA?
Not all disability insurance policies come under ERISA. An employer-sponsored disability insurance policy covered through ERISA contains mandatory federal laws and regulations that you must follow. The type of disability insurance policy you choose will determine the process you must follow to file should you have to appeal for your claim.
Differences between ERISA long-term disability insurance policies and individual long-term disability insurance policies
One of the critical differences between ERISA long-term disability insurance and individual long-term disability insurance is their governance. While individual policies follow the state insurance law requirements, ERISA long-term disability insurance policies follow federal guidelines that employees must follow when applying for benefits and filing appeals.
Because ERISA mostly governs long-term disability insurance policies, the requirements for insurance companies and employees to follow are identical to every claim. That means that every appeal process is identical. Every policyholder gets the same federal rights and must follow the same appeal process.
Why are long-term disability insurance claims denied?
Insurance companies can deny employees’ long-term disability claims for several reasons. Common reasons include a lack of sufficient medical evidence, failing to meet the policy’s definition of disability, and more.
Lack of sufficient medical evidence
Employees are required to provide credible medical records that can validate the extent of their injuries. This requirement includes visits to your primary physician, CT scans, notes from a psychiatrist, and x-rays. Insurance companies have enough grounds to deny your claim if medical records are missing from the claim.
Failing to meet the policy’s definition of disability
Each disability insurance policy contains a summary plan description that clearly explains what the policy defines as a "disability." Each insurance policy includes a definition that you can use to determine whether your condition qualifies. For example, some definitions define a disability as a condition that prevents a worker from any job performing duties, while other policy definitions are broader.
Evidence that contradicts your disability claim
The minute you file a long-term disability claim, insurance adjusters will resort to unethical actions to discredit you. Some unethical actions include taking pictures of you around town without your consent, searching your social media accounts, and taking unauthorized video footage of you as you complete errands. The insurance company can use these types of evidence to justify its decision to deny your claim.
Missed deadlines
Another common reason for long-term disability claim denials is missing deadlines. Each applicant has 180 days to file an appeal against the initial denial. You must submit all required documents during this time because it can affect your ability to file a federal lawsuit against the insurance company. You will not be allowed to sue if you have not exhausted all administrative appeals before filing.
Limits to ERISA disability insurance appeals
There is one challenge, however, that comes with the ERISA appeals process. That challenge involves the requirement to exhaust all appeals before being granted the right to a trial. Before filing a lawsuit against the insurance company for your appeal, you must exhaust all of your administrative appeals before a federal court can review your case.
Another limit to the ERISA disability insurance appeal process is the ability to present new evidence at trial. You cannot submit any new evidence to the federal court, regardless of how it can help your claim. Your administrative record is the only evidence the federal court will consider when deciding your claim.
Limits to compensation in ERISA long-term disability claim appeals
Another limitation regarding ERISA long-term disability claim appeals is the amount of compensation you are allowed to seek through your lawsuit. When you file your federal lawsuit against the insurance company, you can only sue for your disability benefits, attorney fees, and legal costs. That means you are not permitted to seek compensation for damages like emotional distress or bad faith practices against the insurance company.
What factors do the federal courts consider in an appeal?
With the appeal, the federal court is interested in reviewing whether the insurance company abused its discretion. The federal judge wants to determine whether or not credible evidence supports the insurance company’s decision to deny your claim. This standard tends to lean in favor of the insurance company.
How the ERISA long-term disability appeals process works
The appeals process begins once you receive a denial letter from the insurance company. In the denial letter, the insurance company must explain why it denied your claim. After receiving your denial letter, you have a designated 180 days to file an appeal. When you miss the appeal deadline, you permanently lose your right to appeal.
Evidence for your administrative record
Once you decide to file an appeal, you must submit all of the evidence you want the federal judge to consider in your administrative record and your appeal. The types of information you can include in your administrative record include your medical records, letters, or any document provided to you that can strengthen your claims.
Evaluation from a new source
Once your appeal is submitted, a new individual at the insurance company will review it. The new pair of eyes will then evaluate all of the records within the administrative record and speak with medical professionals. During this step, insurance companies have 45 days to decide your appeal. If the insurance company requests additional information from you, they are permitted to suspend all deadlines until you respond to their requests.
Filing a federal lawsuit
If your appeal gets denied, you still have another option that you can take to fight for your long-term disability benefits. This option is only available to you after you have exhausted all administrative appeals for your claim. This requirement means you must ask the insurance company to review its decision before you sue. You will not be allowed to testify on your behalf during your trial. As with your appeal process, your administrative record will be the key to determining whether you will receive your desired verdict.
Why you need a disability appeal attorney
It can be devastating when your ERISA disability insurance claim gets denied. Many decisions may run through your mind as you process how to move forward. One of the best decisions you can make is to seek the legal assistance of a qualified disability appeal attorney.
At J. Price McNamara ERISA Insurance Claim Attorney, our Houston disability appeal attorneys understand how detrimental a denial of disability benefits can be for you and your family. We also understand that insurance companies can cover your benefits but want to avoid paying you what you deserve by any means possible. Our disability appeal attorneys bring several benefits to the table that can assist you with your case.
Identifying what your administrative record is missing
Because your administrative record is vital in your appeal process, you do not want to take any chances of missing any crucial documentation that you can include. An experienced disability appeal attorney can gather all essential documentation in the short period you have. Your disability appeal attorney can also ensure you do not miss the deadline to file your appeal.
Create strategies that can challenge the validity of the insurance company’s decision
An experienced disability appeal attorney can also identify cracks within the insurance company’s decision and use that to your advantage. Should your appeals process transition to a federal trial, the federal judge will use a uniform standard of abuse of discretion. That means the judge will consider whether the insurance company’s decision is valid based on the evidence presented. An experienced disability appeal attorney can provide evidence proving that the insurance company was aware of any errors made on their part and failed to rectify them.
Providing additional legal guidance to a complex appeal process
It is no surprise that the appeal process with an ERISA disability claim is more complex than an appeal with an individual disability claim. The procedures and requirements can be overwhelming for many employees to keep up with. An experienced disability appeal attorney can clarify many aspects of the appeal process.
From reviewing your disability insurance policy to clarifying any confusing legal jargon that the insurance company has used to deceive you. Seasoned disability appeal attorneys can also counteract any compromising evidence against you and provide instructions on how to proceed to prevent the insurance company from continuing to collect any compromising evidence against you.
We are not afraid to take on major insurance companies
What separates our law firm from many is our tenacity. We are not afraid to take on major insurance providers and ensure that they honor the contracts with our clients.
These insurance companies include:
- Mutual of Omaha
- Met Life
- The Hartford
- Sedgwick
- Prudential
- Northwestern Mutual
- Unum
- Aetna
- Lincoln Financial
- Cigna
We dedicate our skill and time to obtaining the outcomes our clients deserve. We have received verdicts ranging from $500,000 to $2 million, provided the case warrants those amounts. Because insurance companies know that we fight for our clients, their response is to offer our clients the benefits they deserve.
Speak to an experienced Houston disability appeal attorney today
You should receive the disability benefits that you deserve. At J. Price McNamara ERISA Insurance Claim Attorney, our Houston disability appeal attorneys have the knowledge, dedication, and resources to challenge the insurance company’s denial. We can offer you the peace of mind you deserve as you practice your legal rights and fight for the compensation you deserve.
Call our Houston office at (713) 300-0462 or complete our contact form for your Free Denial Review with our team.
Houston Office
2000 Crawford St
Suite 1649
Houston, TX 77002
Phone: (713) 300-0462
Fax: (225) 201-8313 (By Appointment)
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