Insurance Benefits Restrictions and Limitations in Texas

Whether you were diagnosed with a long-term illness or were severely injured, the thought of not being able to work for a long period of time can be a daunting one. Financial concerns may run rampant in your mind as you wonder how you will make ends meet.

If you are one of the approximately 50 percent of private sector employees in the United States with long-term disability coverage, you may be breathing a sigh of relief. However, just having access to this coverage may be not enough. In order to obtain these benefits, you must prove to your insurance company that you have an impairment that will hinder you from doing your job.

Proving this fact could be more challenging than it sounds, as the majority of Texas disability claims are denied on the first attempt. If insurance benefits restrictions and limitations in Texas are hindering you from obtaining the long-term disability insurance benefits you have worked for, a seasoned ERISA attorney may be able to help you.

ERISA Federal Law

Employees who have welfare and pension benefits through a private employer or through a union have benefits that are most likely subject to the Employee Retirement Income Security Act, or ERISA. This set of federal laws was enacted in 1974 to set the standards for private insurance companies and to help protect the insured.

Protections provided under ERISA include requirements placed on plan administrators, providers, and beneficiaries for reporting and disclosure, participation, vesting, plan funding, and benefit accrual. Regulation of the responsibilities of plan fiduciaries and plan administration issues falls to the federal Department of Labor.

Restrictions and Limitations on ERISA Benefits

ERISA long-term disability insurance is often subject to approval based on the insurance carrier’s perception of the claimant’s functional impairment. The term “restrictions” refers to activities that the claimant cannot do, while the term “limitations” applies to activities that the claimant can still do but not at the same frequency, intensity, or duration that they could before becoming injured or ill.

However, physicians do not use this terminology in their daily practice. Instead, they are more likely to simply state that the claimant is disabled and cannot return to work at present. Without physicians using the right framework and terms for insurance benefits restrictions and limitations in Texas, an insurer will almost always deny the claim.

On the other hand, insurance companies may have difficulty connecting an injury or illness to a physical impairment. In fact, linking a medical condition to an impairment is usually a complex legal task. Either way, a qualified lawyer may be able to help a plan holder demonstrate their condition through the proper channels and terminology.

Learn More About Texas ERISA Restrictions and Limitations

An experienced attorney may be able to help bridge the gap between insurance terminology and physician language, increasing your chances of approval for disability. More specifically, they may be able to help your insurance company understand how your medical condition has led to an impairment that is not conducive to your line of work or, if applicable, any line of work. Call today to schedule a consultation and learn more about insurance benefits restrictions and limitations in Texas.

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