If your disability insurance policy was purchased through your employee’s benefits program — and has been paid by deductions from your paycheck (or even by your employer) — then your claim is likely governed by a federal law known as ERISA. Disability insurance companies use this employment law and its limitations that have evolved through court decisions to create a challenging hurdle to succeed in the process and to impact claimant’s chances to achieve disability benefits desperately needed.
Insurers act to constrain the entire long-term disability process, from filing a claim, appealing a claim, and litigating a denial in federal court.
A claimant’s chance of successfully fighting a big disability insurance company that has denied a claim is typically an uphill battle. These massive companies have legal departments, teams of medical experts, and outside law firms who do everything they can to deny your claim and fight back against your ERISA appeal, but you don’t have to do this alone.
The New York ERISA lawyers at the Law Office of Justin Frankel can help you through the process of applying for long-term disability insurance benefits and fighting back if the disability company denies your claim. Filing an ERISA appeal on your behalf is an established area of practice at the Law Office of Justin Frankel.
When you receive a denial letter from the long-term disability insurance company, you have only 180 days to file an appeal. If you fail to meet this deadline, your appeal will likely be denied. The right ERISA disability attorney can help you complete and submit all paperwork on time.
There are several different types of ERISA violations we see. The most common include benefits denial, breach of fiduciary duties, and obstruction of employee rights.
Sometimes, people are unfairly denied benefits under their retirement program. If you have earned benefits according to the terms of your employment, ERISA grants you the right to sue for denial of benefits.
Anyone with discretionary authority over your plan management or assets has a fiduciary duty towards you. They are required to run the plan solely for your benefit. If they fail to do so, they are committing an ERISA violation.
Whether the violation is reducing promised benefits, retaliating against employees, stopping healthcare coverage early, or failing to provide required notices, your plan administrator must abide strictly by the terms of the program. If they fail to do so, they violate ERISA requirements.
As mentioned, ERISA, or the Employee Retirement Income Security Act of 1974, is a federal law originally designed to protect employees’ long term disability insurance coverage.
ERISA law and the regulations law were adopted by disability insurance companies and are used to gain control of the appeals and litigation process when ERISA claims are denied.
The first step in battling a disability denial is the mandatory administrative appeal. You cannot pursue litigation (go to court) until you have exhausted your administrative remedies in the claims process (you have completed the appeal process).
The procedures utilized by the courts when deciding ERISA disability litigation frequently deviate substantially from what we think of as typical lawsuits, often to the detriment of claimants. If ERISA governs your disability claim, it’s an uphill battle. Here are a few reasons why:
ERISA attorneys can help you fight for the benefits you need.
Courts often will provide deference to the decision from the insurance company, which makes an effort to succeed further challenging.
Often, courts will not permit discovery to address the insurance company’s significant financial conflict of interest, thus not allowing the claimant to show considerable bias in the process. Additionally, courts often do not permit discovery into the doctors who work on behalf of the insurance companies repeatedly.
A dentist who became disabled wrote about Justin Frankel: He got my claim approved, and now I can start putting my life back together again! Thank you Justin for all of your hard work, dedication, and compassion! If any professionals become disabled, and need to utilize their long term disability benefits, I would only recommend going to Justin Frankel Esq !!!
A 47-year-old woman who had been treated for breast cancer was suffering from the after-effects of chemotherapy. She was a successful neurosurgeon, one of the most challenging medical specialties requiring extensive training — her residency training was seven years. She had a group and a private disability policy from The Standard, which initially paid and then terminated her claims. The Standard relied on an outdated database of occupations that did not accurately reflect the duties and tasks of her challenging career.
Our powerful appeal, which included a strong vocational report, successfully overcame the denials. She is now being paid for both policies. Read the complete story here.
Your most important step following a denial or termination of a disability insurance claim governed under ERISA is to develop an appeal of the denial or termination. Without a thorough understanding of what you are facing and the potential implications of not thoroughly developing your appeal, trouble exists which could potentially foreclose future rights. It’s not something an inexperienced person — even an attorney who doesn’t work in this area — can do.
Your appeal to the disability insurance company has to serve two purposes, and it potentially has two separate audiences. One is to fight back against the denial or termination by submitting the appeal to the insurance company, hoping they recognize the errors and resolve the appeal favorably. The appeal serves to undercut the decision, stripping away the claim support for the denial or termination of the long term disability insurance claim.
The second is to have your claim be as robust as possible to be ready for what happens if your appeal does not succeed. All materials in your administrative appeal must work for a second potential audience — the federal judge, who may ultimately decide whether or not you are entitled to these precious employee benefits. Your appeal must be well-developed and address all the legal issues the insurance company has used for its decision. Saying that you are now and have been disabled is not enough. You must demonstrate how and why you are unable to perform your job or in some cases, any occupation.
The appeal materials must address both the vocational issues involved, including the tasks and duties of your occupation, which are often deliberately misconstrued by the disability insurance company and the medical issues involved. The appeal must also demonstrate that you are under the continuing care and treatment of a physician appropriate to your disability and that your ongoing functional deficits continue to restrict your abilities.
Many other factors go into a disability appeal that must be aggressively presented during this administrative appeal process. And if your claim ultimately needs to be heard before a federal judge, it is imperative to have support for your claim at this critical stage of the process. Hiring a dedicated attorney reassures you that your materials strongly support your case.
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 if necessary. We are constantly learning from court decisions as to how to best advocate our claims for various conditions.
The rules for an ERISA disability appeal are stringent, with defined time frames. Your group disability insurance plan will state whether you can file one or two appeals. Most only permit one level of appeal and then close the administrative record. Others require two levels before litigation can be pursued, as prior to that time, your administrative process has not been exhausted.
The information submitted in an ERISA disability appeal is critical, 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 be permitted to file a lawsuit against the insurance company. Generally, the Court will only consider those materials which were part of this record.
ERISA disability appeals do not permit jury trials, so a judge will decide your lawsuit. This puts your fate in the hands of one person. The volume of ERISA appeals we handle gives us the experience in front of these judges, so we know, in most cases, the audience who will review your materials and consider your future. We know that often, judges see these cases on an infrequent basis, and are not often knowledgeable on the nuances of the medicine.
The standard to be applied by the court may vary. That’s why it’s so important that your appeal be prepared with an aggressive, proactive, and comprehensive approach, covering all of the issues, medical, vocational and legal, which might be brought before a court.
If your ERISA disability appeal is denied and a lawsuit is filed, the court will most likely 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, a judge will most likely not consider them in court.
In order to present a powerful and persuasive ERISA disability appeal, we work closely with our clients, their treating physicians, and often other experts to ensure that the information developed for the appeal contains thorough detail and strong articulation of the severity and degree of impairment and the impact upon our client’s functionality.
We work to dispute 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 occupation, or any occupation, as that term may be defined in the policy, and may differ based upon the insurance company. We work to refute the vocational evidence developed by the insurance company supporting their claim determination. Through this evidence, we are able to secure appeal success and avoid litigation for many of our clients.
Read our related blog post – Top Five Things You Need to Know About Filing an ERISA Long Term Disability
In our view, the ERISA process is stacked against the claimant. Courts reviewing ERISA disability lawsuits often act as a rubber stamp for the claim termination or denial. Despite evidence of impairment, a court can often find some reason to uphold the decision. The standard employed by courts is often more favorable to the insurance company.
The appeal is the only opportunity to create a record for litigation with the hope that the federal court will be receptive to the demonstration of powerful medical support for the claim and wrongful conduct by the insurer.
Another unsolicited testimonial: When you and Justin called me yesterday with the great news that we had won the appeal, it felt like a giant weight was lifted off of our shoulders. We can now start to put our lives back together thanks to the amazing work you guys did putting together a great appeal on our behalf. Thank you so, so much!
Lawyers who do not practice in this specific area of the law are often unfamiliar with the restrictions. The ERISA disability appeals process is a significant part of our firm’s long-term disability insurance practice. We continue refining our best practices as the case law evolves.
Learn more about additional considerations when submitting an ERISA disability appeal.
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 can pursue your claim through a more straightforward process.
These policies are 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 can be fought without the restrictions of ERISA.
A pro-business administration in Washington combined with a powerful insurance lobby means there are no soft-landing places for disability claimants. If your short- or long-term disability claim is denied or you are concerned about filing a New York ERISA claim, we encourage you to contact our ERISA disability law firm at 888-583-4959 to learn how our firm can help protect your claim and your family.
Our legal team stresses that clients should be especially conscious about what they post on social media, as a key government agency has now joined insurance companies in examining social media posts to gather evidence to challenge claims. You may experience one good day a month, but if you or a friend post that positive moment on social media, your ERISA disability claim could be at risk.
Because of our knowledge in this area of law, our experienced New York ERISA claims attorneys represent clients throughout the country, from New York City to California and beyond. Our practice is focused on ERISA claims, and we treat every client like a member of our own family.