ERISA DISABILITY INSURANCE CLAIMS

ERISA DISABILITY INSURANCE CLAIMS

Making a claim for disability insurance benefits can be an involved and complex process. The system designed to review these claims is inherently slanted to the benefit of the insurance company and to the detriment of the person making the claim. It is imperative that competent counsel be retained as early as possible in regards to these claims. There is no initial charge for consultation on these claims and typically these cases will be taken on a contingent fee basis.

Most people have disability insurance policies purchased through their employer. Disability insurance policies are standard from company to company and provide for similar benefits and have similar controlling language. Typically these insurance policies will provide a benefit based upon a percentage of a person’s previous monthly income. During the first two years, disability payments are made for any disability that renders a person unable to do their previous employment. After two years the definition of disability changes to being disabled from performing any occupation. Insurance companies like to use jobs such as a telemarketer in order to deny benefits for individuals after the initial two year period.

Any time an insurance disability policy is part of an employee benefit package, it is regulated by federal ERISA regulations. When an insurance policy is purchased privately by a person through an independent insurance agent, these policies are not governed by federal ERISA regulations. When a disability benefit is governed by ERISA, the procedural rules governing a lawsuit for benefits are slanted heavily in favor of the insurance company.

When filing a claim for benefits under an ERISA disability insurance policy, it is imperative that the appropriate steps and procedures be taken in the case. Unlike other lawsuits where a claimant will have the opportunity to come to court to provide proof that they are disabled, in an ERISA disability case there is no trial. ERISA disability insurance cases end up in Federal Court where the court reviews the decision of the insurance company under an arbitrary and capricious standard.

When a court reviews a decision under an arbitrary and capricious standard, the court reviews the insurance company’s file to determine whether the insurance company abused it’s discretion. In the typical claim for benefits under a disability insurance policy, unless the claimant takes appropriate action, the insurance file will contain very little information in support of the application and overwhelming evidence that supports a denial of the application.

Essentially, disability insurance companies have put together a business plan that maximizes premiums and minimizes the payments of benefits to the people covered under those insurance policies. The standard claim process provides for a certification by the person’s treating physician that they are unable to perform their previous occupation. Typical forms that the physician is asked to fill out are one to three pages long and provide very little information regarding the claimant or his/her claim. Typically, an insurance company will ask for one years worth of medical records and then review this information to determine whether benefits should be paid. It is common for these companies to hire outside physicians to read these records and then write lengthy reports in support of a denial.

Under federal regulations, a claimant is required to exhaust all administrative rights of appeal or they lose their right to sue in federal court. It is essential that an attorney be retained as early as possible when a claimant is filing a claim for disability insurance benefits. When a case is filed in federal court, the only information that will be reviewed is the information that is contained in the insurance file. If an attorney does not take proper steps to ensure that full, complete and compelling medical information is filed in support of the application, insurance companies are known to deny valid claims. If all administrative appeals are not exhausted, a federal suit can be dismissed on that ground alone.

Contact our lawfirm immediately if you are submitting a claim or have been denied benefits.