The Employee Retirement Income Security Act (ERISA), enacted by Congress in 1974, is a federal law which governs employee benefit plans. Almost all employer group long term disability plans are governed by ERISA.
Total disability is defined in your disability insurance policy. This definition can vary from policy to policy. The most commonly used definition of total disability in employer long term disability group plans is defined under the gainful occupation terminology. Under this definition, a disability insurance company will pay your claim if you are unable to perform the material and substantial duties of your occupation, or any occupation for which you are deemed reasonably qualified by education, training or experience. This means that if due to sickness or injury you are unable to work in your occupation, you must also be unable to work in any other occupation for which you may be able to work, even if it means obtaining a job with another employer. For example, if the material and substantial duties of your job is to load and unload trucks all day and due to sickness or injury you can no longer perform these duties, you still may not be considered totally disabled because you may now be able to work in a more sedentary type job, like a clerical office job.
Please understand that as part of your disability insurance company's evaluation of your claim, you may be placed under secret video surveillance, be requested to undergo an independent medical evaluation or functional capacity evaluation. Your insurance company may not have the right to request such evaluations and if they do, they may administer such tests inconsistent with the group policy and plan.
Statistics show that over 70% of long term disability claims are denied. When your long term disability claim is denied, you usually have 180 days to appeal from the date you receive the denial letter. You have the right to appeal the denial as per the instructions outlined in your employee benefits plan. The appeal must be in writing and filed with the insurance company. Usually, if your appeal is denied, you may have an opportunity to file a second and final appeal with the insurance company. The appeal process gives you an opportunity to update your medical records. The filing of an ERISA appeal is probably the most important step in the entire claim process. This can be a very difficult task for an inexperienced person to undertake. The hiring of an experienced disability attorney is highly recommended during the appeal stage.
As per ERISA, you are required to exhaust all appeals before initiating the filing of a lawsuit seeking to enforce your rights. It is very important to know that a federal court may not review any additional material, including witness statements, physician testimony or any medical data not previously provided to the insurance company and plan administrator. All information may be limited to the administrative record. If the filing of a lawsuit is necessary, the suit is brought in federal court with a judge deciding the outcome of the case, not a jury. Typically, the judge reviews the administrative record, a memorandum of law, pleadings and legal arguments submitted by all lawyers and issues a summary judgment. In addition, bad faith laws and punitive damages do not apply in ERISA claims.
The Law Firm of J.P. Gonzalez-Sirgo, P.A. represents individuals that have had their valid long term disability benefits denied, delayed or terminated irrespective of whether the policy was purchased individually or issued through an employer group policy. The firm is available to assist individuals with the initial application process, during the administrative appeals process, handling denials of claims or termination of benefits, litigation in state or federal court, and negotiating a one-time lump sum settlement or buy-out. Please contact our office to discuss your case in more detail.