ERISA Disability Insurance Claim Appeals: When Your Disability Claim is Denied

Disability insurance companies have developed and continue to further develop strategies to succeed when challenged by claimants. Claimants must also prepare themselves for the battleground of ERISA Disability litigation. The first step is the mandatory Administrative Appeal.

ERISA is a federal law originally designed to protect employees’ retirement and welfare benefits. If your long-term disability insurance is part of your employee benefits package, it is typically governed by ERISA (Employee Retirement Income Security Act of 1974).

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Because of some of the strict requirements contained in the ERISA law and the regulations, which govern that law, Long-Term Disability insurance companies use ERISA disability as a means of limiting your options for disability claim challenges.

In Court, very often the procedures utilized by the courts when deciding ERISA disability litigation deviate substantially from typical cases, often to the detriment of claimants. Courts often will provide deference to the decision from the insurance company; courts often will not permit discovery to address the significant financial conflict of interest by the insurance company; and courts often do not permit discovery into the doctors who work on behalf of the insurance companies on a repeat basis (Getting their “bread buttered” by the insurance companies).

Why Is An ERISA Appeal Critical?

Your first step following a denial or termination of a disability insurance claim, when it is governed under ERISA, is to develop your appeal of the denial or termination. However, that is not something easily accomplished without a thorough understanding of what you are facing, and the potential implications of not thoroughly developing your appeal.

Your appeal to the insurance company actually has a second potential audience – the Federal Judge who may ultimately decide whether or not you are entitled to these precious benefits.

Thus, it is absolutely critical that your appeal is well developed – and addresses ALL of the bases upon which the insurance company has relied upon for its decision.

How Is An ERISA Appeal Developed?

To effectively develop your appeal in response to the denial or termination of your short-term or long-term disability insurance claim, you must consider every aspect of the decision, including the medical consideration of your evidence and materials and the vocational considerations of your ability to work or your impairment from working.

We view the insurance company decision as the foundation of a house – to succeed, we try to make the house crumble, taking away each foundation piece.

This is accomplished through our constantly evolving formula for success – which utilizes various tools, resources and strategies to effectively advocate your appeal, and develop the record to enable litigation success.

Rules Governing ERISA Disability Appeals Are Strict

The rules for an ERISA disability appeal are extremely strict, with defined time frames. Your group disability insurance plan will state whether or not you are permitted to file one or two appeals. Most only permit one level of appeal, and then close the administrative record. Others require two levels prior to litigation.

The information submitted in an ERISA Disability Appeal is extremely important, as all of the documents submitted become part of what is known as the "Administrative Record." Following the decision on appeal, and the “exhaustion” of administrative remedies, a claimant will then be permitted to file a lawsuit against the insurance company.

ERISA disability appeals do not permit jury trials, so a lawsuit will be decided by a judge. The standard to be applied by the Court may vary.

In the event that your ERISA disability appeal(s) are denied, and a lawsuit is filed, the court in most cases will limit their review to the documents in the “claim file.” These will be the ONLY documents that can be reviewed during a Federal Court review of an administrative appeal.

This is why the appeal is the most critical time of the claim. If documents are not part of the record, PRIOR to litigation, most often they will not be considered in court by a Judge.

We Can Help You Develop Strong and Persuasive ERISA Disability Appeals

In order to present a powerful and persuasive ERISA disability appeal, we work closely with our clients and their treating physicians, and often other experts, to ensure that the information developed for the appeal contains great detail and a strong articulation as to the severity and degree of impairment and the impact upon our client's functionality.

We work to rebut the medical opinion offered by the insurance company or its hired doctor – using our doctors’ evidence and other collateral evidence and materials to argue why reliance upon these reports is improper.

We also develop strong support for the vocational issues, focusing upon how and why our client cannot engage in work, or cannot perform the duties of either their own occupation, or any occupation, as that term may be defined in the policy, and may differ based upon insurance company. We work to rebut the vocational evidence developed by the insurance company supporting their claim determination.

Read our related blog post - Top Five Things You Need to Know About Filing an ERISA Long Term Disability

The ERISA Disability Administrative Appeals Process Is Not Fair

In our view, the ERISA process is stacked against the claimant. Courts reviewing ERISA disability lawsuits often act as a rubber stamp of the claim termination or denial. Often times, despite evidence of impairment, a court can find “some reason” to uphold the decision. The appeal is the only opportunity to create a record for litigation with the hope that the court will be receptive to the demonstration of wrongful conduct by the insurer and the powerful medical support for the claim.

Lawyers who do not practice in this specific area of the law are not likely to be familiar with the restrictions. The ERISA disability appeals process is a significant part of the firm's long-term disability insurance practice. We continue to refine our best practices as the case law continues to evolve. Read more about our ERISA Disability Appeals success stories.

There are additional considerations when submitting an ERISA disability appeal outlined here.

Private or Individual Long-Term Disability Insurance is Different than ERISA Disability Insurance

If you have purchased disability insurance through an insurance agent on your own, perhaps as a supplement to the disability insurance that you receive as part of a benefits package, then your policy is likely not subject to the same ERISA disability appeals process. You are able to pursue your claim through a more straightforward process.

These policies are more often purchased by high income individuals who need to ensure their specific occupation. They buy what is known as an “own occupation” policy. For example, a neurosurgeon would buy a disability insurance policy to protect her ability to practice neurosurgery.

These types of private or individual disability insurance policies are subject to strict underwriting processes and they can be fought without the restrictions of ERISA.

Current Political Climate Does Not Favor ERISA Disability Claimants

A pro-business administration in Washington combined with a powerful insurance lobby means there are no soft-landing places for disability claimants. If your disability claim is being denied or you are concerned about filing a claim, we encourage you to contact our ERISA disability law firm at 877-583-2524 to learn how our firm can help protect your claim and your family.

We continue to warn claimants be very careful about what they post on social media, as a key government agency has now joined with insurance companies in examining social media posts to gather evidence to challenge claims. You may have one good day a month, but if that good day is posted on social media by you or a friend, your ERISA disability claim could be at risk.

Frankel & Newfield Fights for Claimants Whose ERISA Disability Appeals are Denied

Because of our experience in this area of law, we represent clients throughout the country from our office in New York. Call us at 877-583-2524 or email us to set up a free consultation.

Jason A. Newfield

Written By:

Jason A. Newfield

Disability Insurance Attorney