ERISA and the 18 Mistakes That a Workers’ Compensation Claims Lawyer Can Make
In 1974, the United States Congress passed the Employee Retirement Income Security Act (ERISA), which is the statutory basis for welfare benefit plans, including group health and group disability plans.
Many injured employees have ERISA disability policies, which provide either the payment of short term disability or long term disability benefits. ERISA litigation is a mixture of workers compensation, Social Security, contract law, medical and vocational issues. However, every workers’ compensation practitioner should know that ERISA is complicated and not for the faint of heart.
ERISA’s Short Term Disability Claim Process
Many employers will offer a short term disability policy that provides for the payment of short term disability benefits for as long as 26 months. Your client may have also purchased a long term disability claim, and after they have exhausted their entitlement to short term disability, their claim will be converted by a carrier into a long term disability application.
Most long term disability policies have a 24 month own occupation provision, which also may have a limitation on mental illness or self reported conditions like fibromyalgia.
If benefits are denied, the employee has the right to a full fair review of the denial with only 180 days to perfect an appeal.
The long term disability carrier has two 45 day periods under the ERISA regulations to make a decision to pay or deny these benefits.
It is not uncommon for long term disability carriers to use internal and external peer review providers and even vocational evaluators to review the file.
The crucial stage in an ERISA appeal is the 180 day appeal period as if suit is filed, a federal judge will make a decision based on the status of the record as a time of final claims denial.
The ERISA statute and case law provides for limited discovery and there is no right to a jury trial. That is why it is crucial that you avoid making any mistakes in the handling of an ERISA case. Stay tuned for the upcoming 18 Mistakes in the next couple of days.
Do you have a ERISA or a Workers Compenstation claim? Give us a call today to discuss your claim today, with a free no obligation consultation. 727-894-3188.