ERISA Long Term Disability Claims Frequently Asked Questions


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ERISA/LTD Frequently Asked Questions

Long Term Disability

What is Long Term Disability (LTD) Insurance?

LTD insurance pays you benefits should you become disabled and cannot work. It usually kicks in after 3-6 months (after short term disability benefits expire). While most people think they will not become disabled, it is estimated 1 in 4 twenty year-olds will be disabled for at least 36 months before they retire.

You can purchase LTD plans as an individual, but most plans are provided as part of an employee benefits package.

How do I file an LTD claim?

You will need to fill out an application for benefits. If you purchased the plan as an individual, contact your insurance agent or broker. If it is an employer provided benefit, then contact your human resources department.

In either scenario, you can contact the insurance company directly and get an application for benefits.

There will generally be 3 forms:

  1. Claimant statement
  2. Employer statement
  3. Physician statement

Your insurer will generally provide these forms. But the forms are usually short, with not a lot of space. So feel free to add additional pages as needed.

Please complete the forms carefully, and completely. Any wrong answer can result in your application for benefits being denied.

ERISA

What is ERISA

ERISA stands for Employee Retirement Income Security Act of 1974. Simply put, it is a federal law that governs employer provided retirement and health plans, and almost all other employer provided benefits.

Is my Long Term Disability plan covered by ERISA?

If your plan was provided as an employee benefit, it is very likely to be governed by ERISA. If you bought your plan individually, then state law applies. In general, state laws will provide you with greater protection, especially in states such as California which are consumer friendly.

How does ERISA affect my LTD plan rights?

Even though ERISA was originally intended to protect employee rights, insurance companies have strengthened their position through years and years of efforts. More importantly, ERISA “pre-empts” state laws, including those designed to protect consumers.

What this means is if you sue your insurance company for wrongfully denied LTD benefits, Federal law, and not state law, applies. There is one exception however, and in California, that exception is very helpful to claimants. It is called the “savings clause.”

But in general, ERISA is extremely pro-insurance.

LTD Denials and Appeals

My claim was denied, what do I do now?

You need to prepare an appeal immediately. Do not sit on your denial letter. You need to act fast, as the clock is now ticking. ERISA requires you to exhaust all administrative appeals before you can appeal the denial of benefits.

Why did my benefits get cancelled after two years?

Quite a few policies change the standard for collecting benefits after two years. These are called hybrid plans. The first two years, the standard will be “own occupation.” This means, you will receive benefits if you cannot continue in your current occupation. After two years, the hybrid plan changes the standard to “any occupation.” This means you can’t continue in any other occupation.

A lot of denials occur at this 2 year mark.

How long do I have to appeal the denial of my claim?

You will have a deadline to file an appeal. This will be listed on your denial letter. That deadline is usually 180 days which goes by fast. Your actual deadline may be longer than 180 days out.

Request your claim file immediately. ERISA requires the insurer to send your claim file within 30 days of the request.

Why is an ERISA LTD Appeal so important?

The appeal of the denial of ERISA Long Term Disability benefits is probably the most important stage of your case. First, because if you don’t submit an appeal, or miss the deadline to appeal, you can’t sue in court. Your case is effectively over.

Second, because this is your last chance to “stack” the administrative record. Remember that you have to exhaust all appeals (usually one, but sometimes two) before you can file a lawsuit against the plan. If your appeal is denied, you can file a lawsuit.

But only evidence previously submitted and contained within the administrative record will be reviewed by the court. That means, any information you want the court to know, should be submitted at this stage or earlier. If you fail to include it in your application for benefits or the appeal of a denial, you will most likely not be allowed to introduce it later.

With the deadline and the need to stack the administrative record, you need to consult with an attorney who will ensure deadlines aren’t missed and all necessary evidence be submitted.

What evidence do I need for my appeal?

You will need all of your medical records from treating doctors, including your family doctor and any specialists you treated with. An independent medical exam (IME) and/or function capacity evaluation (FCE) is recommended. If you had any diagnostic testing done, such as MRI’s or CT exams, include these as well. Diagnostic imaging and exams are very helpful because they are “objective findings” as opposed to subjective complaints which are reported by you.

Look at the denial letter, and itemize the list of reasons they gave to deny your claim. You will need to provide evidence rebutting each of their reasons.

Hiring an ERISA Long Term Disability Lawyer

I don’t know if I’m doing this correctly, is there someone who can help?

Yes. Do not sit on a denial. Once you receive a letter denying your application for benefits, contact us immediately. We offer free, no obligation case reviews. If you don’t contact an ERISA LTD attorney immediately, you may be putting your disability benefits claim at risk.

Do I need to hire an LTD Attorney for my case?

ERISA is a complex framework of laws. Layered on top of this is case law in the different federal circuits and the Supreme Court of the United States. On top of all of that, the case law changes frequently, depending on the whims of the courts. This is an extremely difficult subject that even confuses attorneys. You should take advantage of our free case review where you will get your questions answered.

When should I hire an attorney?

The sooner the better. An ERISA LTD attorney will be extremely useful even at the application stage. But the most crucial stage of your case, is the appeals stage. I do not recommend you handle an appeal of LTD benefits without an attorney. Your appeal, is the last chance you have for inserting and including any evidence you want to use at trial later. Without evidence you cannot win your case.

Once the administrative appeal is over, you don’t get to introduce any more evidence. You will not be able to testify in court. There are no expert witnesses. You cannot introduce any more written statements. You don’t even appear in court. The court will review the “administrative record” and case briefs prepared by the attorneys.

We cannot stress how important the claim decision appeal stage is. It absolutely should be handled with the care and experience of an attorney.

How much will an attorney cost? I don’t have much money.

You can hire us immediately with no upfront costs to you at all. We advance all costs, and do not collect a fee unless you are successful in your claim. You don’t owe us any money until you receive money. This is called a contingent fee.  If you don’t recover any money, we don’t get paid. Pretty simple.

So give us a call immediately for your no obligation, free case review. (888) 320-2058.

Be sure to check out our SAQ’s – Should Ask Questions about your LTD Case.