Qualifying for ERISA Long-Term Disability Insurance

August 26, 2022 | J. Price McNamara
Long Term Disability Claim Denials for Chronic Pain - Shocking, but Also Common 
Qualifying for ERISA Long-Term Disability Insurance

Employees have many benefits available to them through their employer. While familiar with health insurance and retirement benefits, you may be unaware of disability benefits. This is a vital benefit you need since workers across the country will suffer injuries, leaving them with debilitating injuries and unable to work. You can be out of work for days, weeks, months, years, and even permanently. If you have questions about ERISA coverage and whether it applies to you, speak with an ERISA long-term disability lawyer right away. Federal law protects employees looking to use these benefits during their time of need. Several states require employers to provide ERISA long-term disability insurance and benefits to their employees, while others do not. When an employer does not provide these benefits to employees when required, they can suffer penalties and fines. The states that currently require disability benefits are New York, New Jersey, California, Rhode Island, and Hawaii. You might think this is good, but it disqualifies many employees from ERISA protections. A caveat of ERISA is the program does not apply to employer disability plans that are “maintained solely for the purpose of complying with applicable … disability insurance laws.”


ERISA is an acronym for Employee Retirement Income Security Act and is a law enacted in 1974 to protect workers. The law covers private health insurance, pension plans, short-term disability, and long-term disability. The way the disability claim is processed, the timeline for the claim, and individuals’ rights for disability are also protected under ERISA. As an employee, you will receive a brochure outlining your rights under ERISA, how the plan works, and your benefits. Employees in the private or public sector can obtain disability insurance benefits. Disability coverage offers employees income they will not receive if they solely depend on social security benefits. It is a significant benefit since you will receive a percentage of the salary you once had. Depending on your profession, you can also purchase disability insurance independently.

What disabilities do ERISA policies cover?

The definition of disability will be the premise of your claim. While some insurance carriers have broad definitions, others have narrow ones. In some cases, disability is when you cannot perform duties for any occupation. At the same time, other policies refer to disability as the inability for you to perform tasks within your career. Upon hitting the 24-month mark, the definition can change. For example, once you hit 24 months, you will notice the benefits shift from your own occupation to any occupation. The definitions will vary; therefore, you can lose your benefits when this change happens. You can qualify for long-term disability depending on various conditions. You must review your policy to find which disabilities you can request benefits for. Cancer is one, but since there are different types, not all will qualify. Cancers that do qualify for long-term disability are:
  • Lung cancer
  • Leukemia
  • Melanoma
  • Breast cancer
  • Lymphoma
Autoimmune disorders make fighting diseases very difficult, and your immune system attacks itself. These autoimmune disorders may qualify for LTD:
  • Type 1 diabetes
  • Lupus
  • Multiple sclerosis
  • Rheumatoid arthritis
Neurological disorders can affect the nerves, spinal cord, and muscles. The ones that often qualify under LTD are:
  • Stroke
  • Epilepsy
  • Migraines
  • Bell’s palsy
  • Peripheral neuropathy
Mental illness is highly contentious with insurance carriers, and many of them won’t pay benefits for them. However, some qualifying conditions include: Chronic conditions last a lifetime, and it is vital to get disability benefits for the ongoing condition. Some chronic illnesses you can get disability for are:
  • Chronic lung disease
  • Asthma
  • Kidney disease
  • Heart disease
  • Fibromyalgia
There are many conditions and diseases you can suffer and need to obtain long-term disability for. While you may see your condition in this article, conversely, you may not. If you do not see your condition, that does not mean you are ineligible for LTD benefits under ERISA. You can still file a claim, but it is best to consult a disability claim lawyer to determine the best legal process and explain your rights under ERISA. ​

Government Worker Benefits

There is some confusion surrounding individuals who work under contracts. Many government employees believe they have additional protections, but most disability benefit plans for government workers do not have protection under ERISA. Do not fret because many public plans offer similar protections as ERISA but under a different name. You will fall into this category if you are a state, local, or federal government employee. It is vital to discuss your protections and coverage with your employer to ensure you can get disability benefits when you need them. ​


Private Company Coverage

In the private sector, most group policies have protection under ERISA. The plan must be employer-sponsored and established by the employer or employee to provide disability benefits to others in the organization. However, ERISA does not cover the plan if the employer fails to make contributions and deems participation voluntary. In that case, the best way to determine your rights under ERISA or other laws is to speak with an ERISA lawyer.

Employer Disability Insurance

While some employers offer disability insurance plans, others do not. Instead, employees will seek coverage individually. There are several ways to discover these options, whether from the employer, a coworker, or open market resources. Remember, if the employer does not pay any plan premiums, you may not qualify for ERISA protection. You must determine how the plan works and your rights and obligations. One of the rights you must look for is what legal options you have when there is a disability claim denial. ​

When does ERISA apply?

Qualifying for ERISA Long-Term Disability InsuranceThere are many protections under the plan, such as employees having access to benefits and coverage information. They must also know how to file a claim and what the deadline to file a claim is. When a claim comes back with a denial, there must be an outlined appeal process for the claims. If the disability benefits claim remains denied after an appeal, the injured party will have the opportunity to file a lawsuit for benefits. You may wonder how workers’ compensation factors into disability benefits, which can be very complex. When a severe injury happens on the job, it will fall under workers’ compensation benefits. Under workers’ comp, you will receive coverage for medical expenses from the workplace accident and some lost wage benefits. A workers’ compensation claim can also face a claim denial like any other insurance claim. Depending on your injury, you can face a workers’ compensation denial and a disability benefits claim denial. Since it is challenging to determine which benefits you should seek to ensure you get the proper coverage for your condition, you must speak with a disability claim attorney near you.

Own occupation and any occupation

You need to know two key definitions for your disability claim: own occupation coverage and any occupation coverage. For most insurance companies, you will see benefits when you cannot perform your own occupation for 24 months and any occupation after that. Own occupation refers to your specific profession, while any occupation refers to your ability to work in any field. Some disability claims are for a few years, while others are until retirement age. While the terms vary, they are vital to your disability claim and ability to obtain benefits. Since there are many technicalities, you will need the help of a disability claim lawyer who can ensure you have the correct classification and therefore get the benefits you need.

Step-by-step LTD process

Applying for long-term disability is an arduous process, and no matter your level of experience, you will need assistance to ensure you have a solid claim from the beginning. To help you, here is a step-by-step list of what you should do to get a successful claim. Do not mistake this as a replacement for legal representation during your claim. The most critical thing you must do is read your policy. Before you do any paperwork, review your policy independently or with the help of a lawyer so you understand what is and is not covered. You can use a Summary Plan Description to see what benefits are available to you. ERISA allows you to obtain copies of these documents once you send a written request. You will need to identify the date of disability, which is a crucial step you cannot get wrong. The date will also affect other parts of the claim, like when you can file, when payment can begin, and more. When reviewing the policy, you should also review how it defines a disability so you can identify the date when you officially became disabled according to insurance guidelines. The last day of work is crucial to your claim. You will need documentation that supports when the last day of work will be. Do not stop working without determining when your last day will be pertinent to your disability. The doctor’s orders must correlate with your last day of employment; if you quit your job before your doctor deems you disabled, you can lose your rights and protections. Deadlines are a vital step in the claim process. The policy will tell you the various deadlines you will need to meet through the process, and you must ensure that you do. When you work with a long-term disability lawyer, they will stay on top of these deadlines and ensure you do not miss any. If you miss a deadline, you can face denial and lose your disability benefits. The most critical step is obtaining medical records regarding your condition. The insurance company will also request these, but you must, too. The insurance company will heavily base its decision about your claim on what is inside the medical records. The records must have MRIs and other diagnostic testing outside your primary doctor’s opinion. You will need a mental Residual Functional Capacity form from a psychiatrist for mental disorders. The most critical step is to speak with a long-term disability benefits lawyer. The process is long and complex, and getting the help you need can be difficult, especially when adjusting your entire lifestyle. A disability claim lawyer can help you through the process and ensure you have protection under ERISA.

How a disability lawyer can help

J.Price McNamara
Long-term disability attorney, J.Price McNamara
While you might be apprehensive about hiring a disability claim attorney, it is often necessary to avoid a claim denial. There are many tasks that a lawyer can accomplish, such as preparing a schedule and strategy. They will also review the insurance policy and other documents pertinent to your claim. Since initial claim forms are vital, you can also get advice from the lawyer on correctly filling them out. Proof is essential for every claim; a disability lawyer will look for all relevant evidence. When the time comes, a lawyer can file appeals, negotiate with insurance carriers and prepare the claim for court. There will be several claim meetings along the way that your attorney can attend on your behalf. The insurance company will often try to speed up the claim process when they see the claimant does not have legal representation. They do this because once the claim reaches the appeal process, you cannot submit further evidence, which can harm your chances of winning in federal court. Sometimes claimants do not file any appeals, which benefits the insurance company. Not only should you obtain legal counsel, but you must ensure it is proper legal counsel. You cannot choose just any lawyer; you will need an attorney with experience in ERISA disability claims. The disability lawyer will know the ins and outs of these cases and can look for all of the proper evidence pertinent to your lawsuit. To get the most out of your claim and ensure you do not relinquish your benefits, you must work with a disability lawyer. Contact a trusted law firm for a Free Denial Review to learn more about how an attorney can help you. When you are in for a long fight, you need an experienced ERISA long-term disability attorney to spearhead your counterattack. You need legal help from the beginning of the process or immediately after learning of a denial.
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J. Price McNamara


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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