ERISA long-term benefits are not always the easiest thing to obtain. You are dealing with an insurance company that has a lot of power and latitude under a law that is exceedingly friendly to them. You have a policy that contains numerous terms and conditions. You can rest assured that each one will be interpreted against you in a heartbeat if the insurance company has the opportunity.
When you need help with a long-term disability claim in Louisiana, you want Lafayette Long-Term Disability Lawyer on your side. We have obtained many high settlements and verdicts, many in the six-figure range, and some in the seven-figure range for our disabled clients, and we bring over 25 years of experience handling disability claims to the table.
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Nonetheless, you must skillfully jump through every single hoop that the insurance company asks if you want to have a chance at getting the benefits that you need. Everything starts with the preparation of your claim. Given the amount of scrutiny that will apply to your claim, you must take great care while preparing it.
Before you submit your claim, you should do the following:
Once you submit your claim, the regulations require that the insurance company issue a decision within 45 days. They may request an extension of 30 days to decide your claim. A fair amount of ERISA long-term disability claims receive a denial at first. The insurance company does not face bad faith allegations when they deny claims. Their only cost is the litigation that happens when you fight the denial.
The insurance company must give you the reason why they denied your claim. They must be transparent about the denial, explaining and showing the work behind it. Once you read their letter, you should have a sound idea of why the company denied your claim.
The most common reasons for denial relate to your medical situation and the policy terms. First, every long-term disability policy will have a definition of the word “disability.” It is the key to whether you can receive benefits. If the medical evidence indicates that you meet this definition, your insurance company should approve your claim.
However, insurance companies often play fast and loose with the definition of “disability.” They may read the term differently than it appears in the plain language of your policy, or they may even change it on the fly so that they can deny you benefits.
The insurance company will also look very closely at the medical records that you have put forward as part of your claim. You will include a statement from your treating physician and the medical records that support your contention of a disability. However, the insurance company does not need to give any deference to your treating doctor’s opinion. They may have their own physician review your medical records and reach their own conclusions.
One of the most common reasons for claim denial is that the insurance company does not believe that you are disabled to the point where you cannot work. They may question your medical information provided. Alternatively, they may even hire someone to follow you or look at your social media to see if your lifestyle matches what you have put down on paper.
There are many reasons why an insurance company may deny your claim. They are enough to cause you significant stress and hassle when you count on long-term disability benefits to pay your bills.
When it comes to appealing your claim denial, there is good news and not so good news:
It may raise a few eyebrows that the same company that denied your claim has the right to check their work to see if they made an error. However, that is precisely what the Employee Retirement Investment Security Act allows. It gives the insurance companies tremendous power and makes things more difficult for claimants.
For claimants who question why they need to expend the effort to ask the insurance company to reconsider their decision, the answer is that it is a required step. If you do not go through the insurance company appeals phase of your process, you cannot proceed further with your appeal.
There are other reasons why you need to take the insurance company appeal process very seriously. First, while we talk about the insurance company’s track record for denying claims, there is always a chance that you can add information to the record and address their concerns.
The insurance company assigns the appeal to a different person than the one who decided to deny your initial claim. There is always a chance that you can win the appeal. After all, the insurance company must incur legal costs to defend against your appeal if you take them to court.
Then, you must also work hard at the insurance company appeals stage because the record at this point of your case is the one that a judge will review in your appeal. If you lose your appeal, ERISA gives you further appeal rights. The insurance company is not the sole decision-maker for long-term disability benefits. A federal judge will review their decision to ensure that it is correct.
However, you do not get the right to have a separate record when your case goes to the federal district court. The appeal does not start from scratch. The federal judge will review the record you sent to the insurance company and nothing more.
If you are missing medical information or other paperwork, you cannot add it to the record in federal court. In limited circumstances, a judge can allow you to add information to the record. If they do allow you to add too much documentation and for the wrong reasons, the insurance company may appeal the decision, and they often do.
The federal judge may use one of two standards of review, depending on the language in your plan’s documents:
Even if the court uses an abuse of discretion standard, you will still get your day in court. If the insurance company’s decision was incorrect, the judge will overturn it. The court may see whether the insurance company has a conflict of interest because it serves the dual role of the payer of benefits and decision-maker for your claim. There are many cases where claimants have won appeals, even using the abuse of discretion standard.
If you do not win at the federal district court, you still have further appeal rights. You can appeal the denial of your claim to the federal court of appeals in your circuit. The rules for this appeal are different. The appeals court is looking at the district court judge’s decision to see if it was incorrect. They will not hear the case from the beginning. They will review the record for any possible error by the lower court.
The ERISA long-term disability process is not easy for claimants. Further, it is not one that you should approach on your own. You should contact an experienced ERISA long-term disability attorney to help with your appeal. You may even consider getting their help before you file your claim if you think that there is a chance that the insurance company may deny your claim. Once you have to appeal, it adds time to potentially getting your benefits. If you can take steps ahead of time to make your claim more robust, you should do what is necessary.
An ERISA attorney can:
Here are some commonly asked questions about ERISA long-term disability benefits. If you have questions specific to your situation, reach out to us directly.
You do not need to pay our ERISA attorneys upfront. Instead, we will receive a percentage of the money you recover. Hiring an attorney often makes the difference between receiving benefits and losing your case, so this is an investment that you need to make. If you lose your appeal, you will not need to pay your attorney. Simply stated, you cannot afford not to make this call.
The ERISA appeals process happens on a tight timeline. You have 180 days after receiving your denial letter to appeal. If you miss this deadline, you will lose your claim.
In reality, you will not want to wait this long because you need the money that long-term disability benefits will provide. In addition, it will take your lawyer some time to work and strengthen your case for the appeal, and you want them to have the time they need.
Yes. Given the built-in advantages that the insurance company has, you do not want to try to take them on by yourself. They have attorneys and an entire legal infrastructure meant to look after their interests, and they do not care about you. An experienced attorney can help put you on more even footing with the insurance company in the legal process. We know how to fight the insurance company, and you can trust us to wage a determined fight on your behalf.
J. Price McNamara ERISA Insurance Claim Attorney has helped numerous claimants over the years when they have run into the standard insurance company red tape that keeps people from receiving benefits. If you have a complex ERISA long-term disability claim or your benefits have been denied, we can help. Reach out to us online or call us today at (225) 201-8311 for your initial consultation with one of our attorneys.
This has been a very difficult time for myself and my family. Mr. Mcnamara did his best to be as empathetic and compassionate as possible. He is very knowledgeable and a man of great integrity.
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