This article explains the ways we help our clients win benefits in their ERISA-based disability claims.
In the video above, we explain how ERISA law makes gaining disability insurance benefits extremely difficult for claimants who are covered by employer-sponsored group insurance plans. But there are ways to get the benefits you deserve, even when your claim is denied.
The Disability Appeal in ERISA-based Disability Claims
When someone comes to us for help, the first thing we do is tell them how important a well-developed administrative appeal is with ERISA disability claims.
How you build and handle the appeal is key to getting your claim paid. It involves much more than submitting medical records and test results confirming a diagnosis.
You Must Prove You Meet the Insurer’s Definition of Disability
The fundamental issue in your disability claim is whether you meet the insurance plan’s definitions of disability. It is your burden to prove that you’re disabled and that you meet these definitions. How do you do that?
In employer-sponsored disability plans, you are required to prove you cannot work in the occupation you were engaged in at the time you became disabled. This definition typically applies only to the first 24 months of your disability case and is known as own occupation.
If your insurer finds that you meet this definition of disability, they will award benefits to you for the first 24 months.
At this point the definition of disability changes to any occupation, a version that is much harder to meet. You must be unable to perform any occupation which may exist in the national economy for which you are educated, trained or suited.
Proving that you cannot work in any occupation, to the insurance company that denied your claim in the first place, is a tall task hindered further by extremely complex laws and procedures.
You Must Show Solid “Proof of Loss” with Compelling Evidence of Disability
All group disability plans will have proof of loss provisions. You will be required to complete a questionnaire or forms asking for information regarding medical conditions and why they disable you from working. There will be an Attending Physician’s statement for your doctor to fill out—and the manner in which this is completed is vital to ERISA-based disability claims. You may also be required to answer questions about issues you have with activities of daily living, and what tasks you are able to do on a daily basis.
Yet even though these insurance company documents ask for specific information, simply supplying this information is rarely enough to cause an award of benefits. In fact, this is the first glimpse into the strategy of the insurer. To the untrained eye, you are providing everything they have asked for.
Think of the proof of loss requirements as just the starting point. Our law firm makes sure for every ERISA claim we file or denied claim we appeal, we meticulously stack the deck in our client’s favor.
You Have a Short Window of Time to Appeal
The only time you can add evidence to your claim file is while your initial claim is pending, or during the administrative appeal stage. Normally you have just 180 days to appeal the denial.
In ERISA-based disability claims, the completeness and integrity of your appeal are essential to your success. The appeal is the only chance you have to submit vital evidence of your disability into the records.
If your appeal is denied and you proceed to court, you will not be allowed to submit this evidence later in a lawsuit. The only evidence considered at trial is the evidence submitted during the administrative appeal.
This is why you must “load the record” now with medical and vocational evidence that will solidly support your claim and prove you meet your insurer’s definition of disability.
We apply a comprehensive strategy for each claimant we assist, often developing their case file with vocational export reports, testing for residual functional capacity, objective medical testing, physicians’ opinions, lay witness testimony and other evidence.
ERISA-based Disability Claims Are Different.
View your claim from a critical perspective. You can bet your insurance company has their own plan of action, and you must have one as well.
If you have been denied your rightful benefits, don’t give up! Talk to an experienced long-term disability lawyer at Marc Whitehead & Associates.