In our video above, disability attorney Marc Whitehead discusses the importance of the administrative appeal in group disability claims.
Group insurance plans are governed by federal ERISA law. There are key differences between what you must do to prevail in a claim for group disability benefits under ERISA rules, versus the state contract laws that you would follow if your claim were filed under a private long term disability policy.
ERISA disability claims can be difficult to win. The information below explains just a few ways the deck is stacked against claimants in an ERISA-based disability claim. Only with an experienced attorney in your corner do the chances for a favorable outcome increase considerably.
Group Disability Certificate of Insurance
Group disability insurance coverage is generally issued in the form of a Certificate of Insurance under the group plan.
With group coverage, you are not issued a personal policy that is adapted to you as an individual. Instead, you enroll for coverage under a plan that is issued to the business or organization that represents your “group,” such as company employees and professional association members.
If all or part of your claim is denied under a group plan, you must appeal the denial within 180 days. If you do not file an administrative appeal, or miss the deadline, you may lose your case.
The Administrative Appeal is the Most Critical Step of a Disability Claim.
In a nutshell, a group claim is decided based on the contents of the “administrative record.” After an initial decision of denial, the administrative appeal is your last opportunity to submit supporting evidence into the administrative record proving your claim.
If the insurer continues to deny the appeal, the next step is litigation in federal ERISA court. At that time, your case must be able to stand on the facts presented in the administrative appeal, because you cannot add further evidence to your case.
Own Occupation Coverage Period
Group plans typically have an initial 24-month “Own Occupation” coverage period. For the first 24 months of the claim, the definition of “disability” is that you are unable to perform the material and essential duties of your own job.
Any Occupation Coverage Period
After 24 months the policy’s definition of disability switches to the harder-to-prove “Any Occupation” wording. If you are prevented from performing any occupation, now you must prove that you cannot perform any job for which you are reasonably qualified. In the appeal, you need to develop a case with evidence that will stand up to this shifting definition of disability.
This is a much tougher task. That is why the broadening of the definition after 24 months frequently results in claimants’ LTD benefits being cut-off or terminated at the two year mark.
Add to that the power the insurance carriers have on a claim. Not only does the insurer define disability; it also interprets policy provisions and decides whether you are disabled or not. This produces a fundamental conflict of interest.
It takes an experienced disability insurance lawyer to effectively demonstrate how such a conflict of interest may have influenced the insurer’s deliberations of denial.
ERISA Disability Lawyers Fighting for You
When it comes to appealing a group disability claim denial, insurance companies can be difficult to work with. If you filed a claim under your company’s group plan and were wrongfully denied benefits, you are in the company of thousands of other disabled claimants.
Do not give up hope. Our law firm helps people across the U.S. fight unfairly denied disability claims against the nation’s largest insurance companies. We represent clients in the administrative appeal stage throughout Texas and nationally.
When you are chronically ill, or disabled through physical or mental impairment and cannot work, we can help.
Read more about the differences in ERISA rules and private disability insurance laws that will determine how your disability claim must be handled to win the benefits you deserve.