Long Term Disability Claims Under ERISA: The Law, The Claims Process, and Secrets to Help Win Your Case
The Unthinkable Happens.
You've worked hard in your career for years. With every paycheck you have received, it is likely that your employer has deducted partial premiums for private long term disability (LTD) insurance. These insurance policies are issued and administered by huge private insurance companies. These policies are supposed to provide you with monetary benefits (usually 60%-80% of your normal earnings, depending on the policy), in the event you become disabled due to injury or illness.
Like most people, you probably don't think twice about what that payroll deduction is going towards, until the unthinkable happens, and you find yourself disabled and unable to work. Most expect that their LTD insurance policy will be there as a safety net, insuring that you and your family will be able pay the bills in your time of need.
Unfortunately, most claimants who find themselves disabled and out of work, will face denials of benefits from the companies that administer these LTD policies. The law that governs these policies is known as ERISA, which is an acronym for The Employee Retirement Income Security Act of 1974, 29 U.S.C. 1132. This federal legislation has caused more stress for disabled workers, and allowed insurance companies that issue LTD policies to act with impunity in denying valid claims, than any piece of legislation in American history. However, the more you know about ERISA and how these claims are handled by our federal courts, the better your chances are of leveling the playing field and getting the benefits you deserve.
If your claim is denied, it has been reviewed by a plan administrator, an employee of the insurance company who is given virtually endless discretion in determining whether to deny your LTD claim. Before you can pursue the denial of your claim in federal court, you must first exhaust your administrative remedies. This means you must completely submit your claim to the internal appeals procedure put in place by the insurance company. There are often many levels of appeals, usually with the same result: claim denied. Once you have exhausted your administrative remedies, you finally have a right to file a lawsuit.
Long Term Disability Claims in the Courtroom.
Once your case is in federal court, things get even stranger. The LTD case is not tried in the traditional sense. There are no testifying witnesses, no cross examinations, and no closing arguments by lawyers. To the contrary, most LTD cases are simply decided by a federal judge who examines the administrative record, which is your claim file, as compiled by the insurance company. Think of it as a basket in which all the relevant documentation to your claim is dropped, including: questionnaires completed by you, your medical records, and statements of treating physicians as well as those of the hired gun physicians employed by the insurance company. The administrative record is the only evidence reviewed by the federal judge in a LTD case.
Under the law, after reviewing the administrative record, the court can only reverse a LTD denial, if it finds the insurance company's determination was arbitrary and capricious. This means there was no evidence, at all, to support the insurance company's denial.
Is There Hope?
Sounds like a pretty unfair process doesn't it? The passage of ERISA certainly was a coup for the insurance industry. It allowed them to deny thousands of claims, and effectively keep disabled claimants from obtaining the justice they deserve. Nonetheless, LTD cases brought under ERISA can still be won if you take certain steps to level the playing field.
Building Your Case by Supplementing The Administrative Record.
Under ERISA law, the administrative record cannot be supplemented with any evidence once you receive your final denial on your claim from the insurance company. The file is closed. Remember how I previously said to think of the administrative record as a basket in which certain documentation is placed relevant to your claim? Therefore, it is extremely important to fill that basket with as much favorable evidence as possible, which supports your claim that you are indeed suffering from a long term disability. So, how do we do that?
First and foremost, it is absolutely crucial that you get an ERISA attorney involved in your claim as soon as you are denied by the insurance carrier, who can start taking steps to make the administrative record more favorable to you. We can do that numerous ways, including supplementing the file with client testimonials about their daily activities and abilities. (This is about as close as a LTD claimant will come to testifying in ERISA cases). I often also use the assistance of Vocational Experts, persons qualified to testify in court as to a claimants loss of access to jobs in the national economy. Vocational Experts will often author detailed reports regarding our clients disabilities which a judge will read and consider when making the final judicial determination in a LTD case. Furthermore, some cases warrant the use of independent physicians who will examine our clients and provide a disability assessment report and offer opinions as to whether an individual has the functional ability to be employed.
Tricks You Can Use to Maximize Your Chance of Success.
The client can also take steps to increase their chances of winning a LTD case. Make sure to gather all your medical records and review them for accuracy. I have had more than one case where the insurance carrier told my client that their treating physician said X, when in reality, the doctor said Y. Reviewing your own records helps keeps the insurance company honest. Next, keep a very accurate list of the names and addresses of all health care providers you have seen for your illness and injury. This makes gathering medical records much easier for your attorney. In addition, make sure that you carefully read those lengthy letters that you receive from the insurance carrier during the claims process. These often contain deadlines pertaining to appeals periods, and when the administrative record will close. Further, if you send anything to the insurance company, send it certified mail, and make a copy of all documentation sent. Next, be VERY careful what you say to the adjuster handling your LTD claim. They will turn the most innocuous statement into a claim-denying event. Also, if the insurance company sends you questionnaires, fill them out as completely as possible. If the insurance form doesn't provide you with enough room to relate the circumstances of your condition, attach additional pages. Finally, be aware that insurance carriers often hire investigators to spy on you, usually shortly prior to physician exams, or independent medical evaluations that are set up by the insurance carrier.
In sum, ERISA governed LTD cases are won (and lost) by what is in that little basket of evidence called the administrative record. Consulting with an attorney as soon as possible after you receive a letter from the insurance company denying your LTD claim increases your chance of obtaining a favorable outcome. ERISA attorneys can use many resources to supplement the administrative record with information that can force the insurance carrier to pay the long term disability benefits that you deserve.
Copyright 3/4/09 by Brent H. Jordan, Attorney at Law