Like every other worker, you expect the fact that your company offers a long-term disability insurance policy to mean something when the time comes that you need it. However, you often run into the unfortunate reality of these policies. Insurance companies know exactly what your claim is worth and often do everything they can not pay them. Although you can fight back legally, it is not always easy. You should have the help of an experienced attorney in an ERISA case, given what is at stake.
J. Price McNamara ERISA Insurance Claim Attorney represents clients with disabilities and injuries against all of the nation’s biggest underwriters, and we fight for the best results possible in every case. Reach out to consult our legal team about your situation today.
When you file a claim, you start with the language of your plan. Your long-term disability plan is a legal document that states the insurance company’s obligations to you and what you must do to qualify for benefits.
There are several critical parts of your long-term disability insurance policy:
When you find yourself unable to work because of an injury or illness, you must make a compelling case to the insurance company in your initial claim that you meet the plan’s definition of the word disabled. The insurance company will not take your word for the fact that you are disabled. They will want to see proof, or else they will deny the claim.
You may use the following to show the insurance company that you are disabled:
Even with all the evidence you provide supporting your claim, the insurance company may deny your application for benefits. The truth is, they may not even pay much attention to the documentation you provide. They are looking for any reason to deny your claim.
When the insurance company denies your claim, they must provide you with the reason why and any documentation they relied on to reach this decision. You may be shocked that the insurance company paid very little attention to the statement of your treating doctor. They may have their own hired “independent doctors” who review your medical documentation and reach conclusions, excluding your doctor’s opinion.
Here are some reasons why insurance companies will deny your ERISA long-term disability insurance claim:
The insurance company’s denial often comes as a shock to claimants. They are angry and question whether the insurance company can get away with it despite clear evidence of your disability. The answer to this question is yes and no. ERISA does not allow you to sue an insurance company for a bad faith denial of your claim because it preempts state insurance law. However, you have the right to file an appeal that challenges the denial of your claim.
Despite a clear appeals process, it does not necessarily work in your favor from the outset. While ERISA was passed as a law to protect employee benefits, you get very little protection from ERISA. In other contexts, you can sue the insurance company in court and have a judge or jury decide whether the company breached its contract. They may even be penalized if they acted improperly.
The appeals process under ERISA is entirely different. Many people are shocked when they learn they file their first level of appeal with the insurance company itself. You must somehow persuade the same company that denied your claim in the first place that it made a mistake and should grant you benefits. In practice, this rarely happens, but theoretically, it can (at least according to ERISA).
Nonetheless, you must fully participate in the insurance company appeals process, no matter how much you think it may be a kangaroo court. The insurance company promises that different people will consider your appeal than the ones who deny it in the first place, but that is not why you must expend time and effort to appeal to the insurance company.
While you will get a right to go to federal court if the insurance company denies your appeal, the federal judge will not start your case from scratch. You will not get to build a record and have your side of the story heard like you would in a normal lawsuit. The ERISA federal appeals process envisions a quicker case where the judge decides based on the record. You will have your appeal file and a personal statement, and your lawyer may write a brief that explains your position.
However, you do not get to add to the record that you built when the insurance company heard your appeal. The judge will only look at the documentation that the insurance company saw, and they will not let you add anything more to the record because it is locked down. There are limited exceptions to this rule. Therefore, you cannot start in the middle of the process and skip the insurance company appeals process.
Here is the order of the appeals process:
Insurance companies will often fight long-term disability appeals for years. While the insurance company can fight as long as they want, it does not mean that they get away with delaying your case. If they lose, they will need to pay you back benefits to the date when you filed the claim.
An insurance company may try to offer you a settlement while your case is litigated or even after they decide to grant you benefits. A settlement may pay you less than you may get through a lawsuit. Discuss any settlement offer with your attorney. Like any settlement, you can negotiate with the insurance company.
When you are dealing with an ERISA long-term disability insurance case, there can be hundreds of thousands of dollars on the line and perhaps more. A long-term disability policy can pay you up to 70 percent of your earnings before you were disabled. If you were disabled at a younger age, your claim can even be worth more than $1 million. Therefore, it is in your best interests to get legal help sooner rather than later.
Here is what an experienced ERISA attorney can do to help you and your family:
Money means something to an insurance company, but it means everything to you because you need to continue to pay bills when you cannot work.
If the insurance company denies your claim, you cannot easily stand up to it on your own. In some respects, ERISA gives the insurance company a home-field advantage, but it is one that you can overcome when the facts and law are on your side with the help of an experienced lawyer.
Even when the insurance company awards you benefits, you are not done with it. You must exercise caution because they may still find a way to terminate your benefits.
Some insurance companies change the rules of the game as they go along. They may change the definition of disabled after a certain point to only give you benefits if you cannot do any work, as opposed to the work you did before the injury.
The insurance company wants and expects you to go back to work because it saves them money. Many times, they will even terminate benefits when someone still suffers from a serious medical condition. If the insurance company wants to examine you, hire our lawyers.
The process for benefits terminations is the same as it is for claim denials. You will still need to file an appeal with the insurance company and then take your case to federal court if you lose the appeal.
When it comes to long-term disability benefits, you should hope for the best but prepare for the worst. Every company that offers these plans pitches itself as caring lifesavers when you need them, only to try to stiff you when you need them.
Insurance companies can drag these cases out for years, and you must find ways to beat them at their own game. You need to hire an attorney with a track record of taking the fight to the insurance company because that is what you often have to do.
If you have an ERISA long-term disability benefits claim, J. Price McNamara ERISA Insurance Claim Attorney can help you. We have a track record of standing up to insurance companies on behalf of clients and getting benefits when the insurance company has devoted its efforts to deny them.
To learn how we can help you, call us today at (504) 420-6962 or reach out to us online for your free initial consultation. We will aggressively work to protect your legal rights under your plan and ERISA and get you what the insurance company wrongfully denied you.
829 Baronne Street
New Orleans, LA 70113
Phone: (504) 420-6962
Fax: (225) 201-8313
“Price is very professional, honest, and reliable. Whatever he says, he will follow through with the utmost integrity. He will turn over every stone and pays close attention to even the smallest detail.”
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