We provide comprehensive assistance to employees who are participants in their employer’s disability plan and independent professionals.
We provide comprehensive assistance to employees who are participants in their employer’s disability plan and independent professionals who individually purchased disability policies to provide financial security in the event of a disability. Our services can be divided into four areas: application, appeal, claims monitoring and litigation.
If you are receiving benefits through your employer’s group benefits plan, your claim for benefits is largely controlled by the Employee Retirement Income Security Act (ERISA) and the plan’s terms and conditions of coverage. If you purchased a plan individually, your claim for benefits is largely controlled by state insurance and contract law as well as the plan’s terms and conditions of coverage. Unfortunately, ERISA gives insurance companies many outlets to delay or deny a valid disability insurance claim. Insurers face no real penalties for denying ERISA claims.
With nothing to lose, they often use this to their advantage to unfairly avoid paying out disability benefits. In the case of ERISA controlled plans, a large precedent of law has been churning for years that may limit your rights and remedies – including limited review of a plan’s denial, limited availability of damages and attorney fees and no right to a jury trial. State law claims still allow for fairly expansive rights and remedies.
Application for Benefits
If at all possible a denial of benefits should be avoided. It may otherwise take at least a year to be awarded benefits during the appeals process. We will work with you to collect your medical and vocational information, advise you on your plan’s structure, requirements, coordination with other benefits and limitations of coverage. We will also work with you and your medical providers to present the best possible case of disability under the plan and not prejudice your claim for future benefits. Ultimately our goal is to present comprehensive chronology to the insurer that shows your medical condition fits within their definition of disability under the plan documents and is not considered one of the plan’s increasingly large number of exclusions to coverage.
The Appeal Process
If a claim is denied, more than half are, the appeal is the best chance for the claimant to have the matter overturned or at the very least set the case up for a successful lawsuit. The internal appeal process is mandatory before filing a lawsuit, and for the group plan policy holder, the evidence submitted during the appeal is largely all the evidence that will ever be considered by the insurer or by a court. A well-established precedent of law also includes that courts often must limit their review of evidence to that submitted in the administrative appeal, and are often limited in their review of the evidence. Given this, it is essential to build the case during the appeal.
Insurers use all sorts of tactics to deny claims; e.g. “independent” medical reviews and exams, vocational reports by experts to which they regularly refer work, surveillance, claims of malingering, claims of non-objective evidence of pain, non-compliance with treatment, not comprehensively reviewing interaction of multiple medical conditions and/or “cherry picking” the records for evidence of ability to work. Thankfully the insurer is mandated to provide the complete claim file along with an explanation regarding why it is denying benefits.
It is crucial to go through the claim file – looking for procedural irregularities, conflicts of interest, inaccuracies and outright misrepresentations – and to submit contrary evidence and rationale in support of finding disability. Likewise, claimants should have their best case put forward in regard to their version of events (such as surveillance), their treating physician opinions, vocational ability and anything else that may support the finding of disability.
It is important to note that there may be a time limit of as little as 180 days to file an appeal. You should not wait to contact an attorney, and you should keep both the denial letter and the envelope in which it was mailed.
If you have been awarded benefits (“on claim”), unfortunately, the story does not end there. There may be exclusions and limitations in your coverage that allow the insurer to end coverage at a given point in time. Likewise, the plan requires you to continue to comply with records provisions, and the plan may reopen the matter. If you fail to do so, your benefits can be limited or terminated. It is important to control the information being provided to the insurer. For example if you have more than one condition, one of which is limited to two years of coverage (as is the case with mental impairments in most policies), it is important place emphasis on your physical condition as the impetus for any mental disorder.
Likewise, your doctors may inadvertently provide information to the insurance company or plan that may lead to the early termination of your benefits. Frequently, doctors complete disability forms quickly and without looking at the file. This may be avoided by having an experienced attorney review your medical information before it is sent off to the insurer.
Where and under what procedure a disability matter is litigated largely depends on whether it is an employer group plan or a privately purchased plan. Privately purchased plans are litigated in state courts and are controlled by insurance and contract laws of the state. Employer group plans are litigated in federal court and controlled by the Employee Retirement Income Security Act (ERISA).
Litigating in state court is by no means easy, but any knowledgeable attorney in this area will tell you it is preferable to an ERISA matter. This is because ERISA limits the evidence considered, disallows a jury trial, gives the insurer’s view of the evidence deference and generally limits recovery to only the plan benefits that should have been awarded in the first place.