When you start a new job, you probably spend a chunk of time in the first few days going over your benefits. If you have the option to participate in a disability insurance plan as part of this process, then your policy may be covered by a federal law known as ERISA. This law is designed to protect workers when it comes to employer-sponsored employee benefits.
ERISA requires insurance companies to disclose certain information and comply with strict standards for administering claims. Despite these protections, it isn’t unusual for workers to have their long-term disability claims unfairly denied or terminated. Our seasoned ERISA disability attorneys will work with you to build a strong, well-supported claim and will help you file any necessary appeals.
At Bross & Frankel, we are dedicated to helping people with disabilities get the benefits that they are entitled to under the law. We represent people as they seek all types of disability benefits, including long-term disability, Social Security disability, and veterans’ disability. Reach out today to schedule a free claim review with a member of our legal team.
What Is ERISA?
The Employee Retirement Income Security Act of 1974 – more commonly referred to as ERISA – is a federal law that sets standards for employer-sponsored retirement and health plans. It also applies to long-term and short-term disability insurance coverage that is provided by an employer. The goal of ERISA is to protect workers who have privately offered employee benefits such as retirement, health, and disability plans.
Under ERISA, employers and/or insurance companies must provide participants with certain information, including a summary of the plan, how it works, and what benefits are offered. Under ERISA, an employer-sponsored plan must also comply with regulations related to how disability benefit claims are processed, the timeline for processing a claim, and an appeals/grievance procedure.
Because the goal of ERISA was to protect employees, having an ERISA disability insurance policy can be beneficial. As an initial matter, under ERISA, the insurance company is considered a fiduciary. This means that the insurance company must act prudently and in your interest when administering a claim.
ERISA also requires long-term disability insurance companies to disclose relevant information to policyholders. In addition to providing insureds with a plan document, if your claim is denied, the insurance company must provide the specific reasons for the denial and give you access to the claim file.
In addition, under ERISA, long-term disability insurers must provide you with a “full and fair review” when deciding your claim. This means that the insurance company must adopt reasonable claims procedures, allow you to appeal a claim denial, make a decision on a disability claim and any appeal within a short time period, and review all of the evidence that you submit. Finally, if you believe that your application for benefits was wrongfully denied or terminated early, you may be able to file a lawsuit against the disability insurance plan in federal court.
Is My Disability Plan Covered By ERISA?
If you have disability insurance – including short-term and/or long-term disability insurance – through your employer, it will most likely be governed by ERISA. This law covers most private group disability plans, other than those established or maintained by governmental entities or churches. Disability insurance offered through a union or employee group may also be covered by ERISA.
For most people, if you obtained your disability insurance at work, then your plan is likely covered by ERISA. However, if your employer does not make any contributions to the plan and it is completely voluntary, then it may not be considered an ERISA plan. If you have questions about whether your disability program is covered by ERISA, reach out to a New Jersey long-term disability lawyer to learn more about your rights and options for filing an appeal.
Applying for Long-Term Disability Benefits
Long-term disability (LTD) insurance is a specific type of insurance policy that pays a percentage of your salary in cash benefits if you are unable to work due to a disability. While each plan is different, to be eligible for long-term disability benefits, you must generally (1) have a covered disability under the terms of your policy and (2) be unable to work because of that disability.
Applying for long-term disability benefits can be challenging. Even if you were already approved for short-term disability, you will probably need to file a separate application for LTD benefits.
The first step involves carefully reading your insurance policy to determine what is considered a disability and what may be excluded. For example, many LTD policies do not cover pre-existing conditions. You will also need to determine whether your policy requires that you cannot work in “any” occupation or just in your “own” occupation.
Next, you will need to request an application from your company’s human resources (HR) department or through an online portal. Importantly, while HR can be a valuable source of information when it comes to plan documents and applications, they are not a replacement for a New Jersey ERISA disability attorney, who can advise you of your legal rights and develop a strategy to increase the likelihood of your claim being approved.
As part of the application, you will need to provide an employee statement that describes your work history, educational background, and information about your disability. Your employer will also have to submit certain information, such as your hire date, job description, and job requirements. You will also typically have to sign an authorization that will allow the insurance company to request your medical records to determine your eligibility for benefits.
The LTD claim process is filled with potential pitfalls. An insurance company may deny an application for benefits for several reasons, including:
- Insufficient medical evidence
- Pre-existing medical conditions
- Changed definition of disability after 24 months
- Failure to meet the definition of disability under the plan
- Missed deadlines
- Paperwork errors
- Other evidence that undermines your claim (which may come from an investigation into you or even your own social media posts)
- Conflicting medical assessments
A New Jersey long-term disability lawyer can help you put together the appropriate supporting evidence and advise you on what you may need to do – or not do – for your claim to be approved. If your claim is denied, they can help you understand the appeals process. This typically includes a requirement to file one or two administrative appeals before moving forward with a federal lawsuit.
How an ERISA Disability Lawyer Can Help You with Your Claim
Most people believe that if they pay for insurance, then any legitimate claim should be covered. Unfortunately, this isn’t always the case. Even if you have an illness or injury that is covered under your disability policy and cannot work because of it, your claim could still be denied. An ERISA disability lawyer can help.
Insurance policies are a type of contract. They are often lengthy, and incredibly technical. Most people have a difficult time understanding the terms of their contract, and how long-term disability laws like ERISA may apply to their situation.
A New Jersey long-term disability attorney can help with the initial application for benefits. They can gather the necessary medical evidence to support your claim and assist you with the application paperwork. They will also carefully review your insurance policy to help you understand what is and is not covered – and how to maximize the benefits that you may be entitled to under the terms of the policy.
If your claim is denied, then your lawyer will thoroughly examine the denial notice and start building a case for an appeal. They will file an administrative appeal within the appropriate time frame (180 days). If your administrative appeals are exhausted, then they will draft and file a federal lawsuit against the insurance company to protect your rights.
Working with an ERISA disability attorney from the start can help to improve the chances that your LTD claim will be approved. Even if you don’t hire a law firm until after your application is denied, a lawyer can still help you file the necessary appeals and help you get the benefits that you deserve. They can also assist you with related matters, such as filing for Social Security Disability benefits.
Call Bross & Frankel to Talk to an ERISA Disability Attorney
Long-term disability insurance is designed to protect people who can’t work because of an illness or injury. Too often, getting approved for LTD benefits is incredibly challenging. An ERISA disability lawyer can help you understand your rights and advocate for you from the initial claim through any appeal.
From our law offices in Cherry Hill, Bross & Frankel represents clients throughout Pennsylvania and New Jersey who are seeking disability benefits. We have substantial experience in all aspects of disability benefits law, which we put to work to help our clients achieve the best possible outcome for their cases. To learn more or to schedule a free initial consultation with a New Jersey long-term disability attorney, give us a call at 866-708-3985 or fill out our online contact form.
How Will the Insurance Company Decide My LTD Claim?
Many long-term disability insurance companies make decisions based on “paper reviews.” A medical professional will review all of the medical records and other supporting evidence that you submitted, and then make a decision about your claim. This often occurs without an examination or assessment to determine if you are disabled.
Paper reviews can often lead to unwarranted claim denials. A New Jersey ERISA disability lawyer will gather evidence to support your claim and will help you appeal any wrongful denials. Reach out to Bross & Frankel to schedule a free claim review.
I Have a Pre-Existing Condition. Can My LTD Claim Be Denied?
Possibly. Many disability insurance policies contain an exclusion for pre-existing conditions that occur during the first year of coverage. It can often be hard to determine whether your medical condition will be considered pre-existing, and how that affects your claim. A seasoned ERISA disability attorney will review your policy and help you decide how to move forward based on your unique situation.
At Bross & Frankel, we pride ourselves on going above and beyond to help our clients get the benefits that they deserve. Contact our law firm today to schedule a free consultation with a member of our legal team.
I Missed the Deadline to File an Appeal. Can I Still Sue the Insurance Company?
Long-term disability plans that are covered by ERISA are subject to strict regulations about how claims are processed. This includes deadlines and procedures for filing an appeal. If you fail to file an administrative appeal after a claim denial, then you will likely be unable to file a federal lawsuit against the insurance company.
Long-term disability claims can be complex, and it isn’t always easy to know what to do – and when to do it. If you are considering filing an LTD claim, you don’t have to do it on your own. Contact Bross & Frankel to schedule a free claim review with a New Jersey ERISA disability attorney.
Related: How to File an ERISA Claim