ERISA stands for “Employer Retirement Income Security Act.” It was passed in 1974 for the purpose of protecting employee benefits for group plan participants. Unfortunately, disability insurance policies are subject to the ERISA regulations, which long-term disability carriers refer to as “Everything Ridiculous in the World Since Adam.”
ERISA, which is a federal statute, pre-empts state law. That means that there are no state law causes of action, including bad-faith claims handling.
I am sure that your HR manager thought that having a group LTD policy would be a great benefit to the employees and is part of a benefits package that most employees are quite happy to have. These policies are cheaper, easier to sell, and are probably more profitable for the long-term disability insurance companies. How does it become profitable? ERISA procedures set up an administrative process, and you must read your policy closely to understand that process. There are specific time periods in which you must report your claim, submit information in support of your claim, and time periods in which the insurance companies or claims administrator must deny your claim.
There may even be an internal appeals process in the event that your claim has been denied.
Unfortunately, you must follow this claims process to the letter until you “exhaust your administrative remedies.”
Long-term disability lawyers such as Cavey & Barrett more often find that the claimant has been exhausted by the administrative remedies as opposed to getting a favorable decision.
You should also remember that there is no such thing as a treating physician rule that gives deference to the opinions of your treating physicians. The long-term disability carrier can and many times ignores what your physician has to say about you and your ability to work.
These ERISA procedures are used to sabotage your claim. Under ERISA, the long-term disability carrier has to provide you with an explanation for its decision as well as documentation that it relied on in making the denial. Allegedly, this give you multiple opportunities to cure the defect.
In reality, the long-term disability insurance company will have your file reviewed by a peer review physician or have you evaluated by a physician of their choosing. The insurance company’s claims denial is almost perfunctory and the insurance company will simply be happy to take a defensive posture, sitting back and taking apart your claim.
Since there is no treating physician rule, so long as the long-term disability carrier follows the ERISA regulations by having its team of internal medical consultants and experts address your medical documentation, it can be difficult to overturn the group carrier’s decision to deny your claim or terminate your benefits.
It is crucial that you have an experienced long-term disability attorney help you even before you file your claim for long-term disability benefits. Nancy Cavey, who is highly experienced in representing long-term disability applicants, can assist you in understanding your long-term disability policy, assist you in perfecting your claim, and providing the long-term disability carrier with documentation to defeat every company’s strategy that will be employed to deny your claim.
Group long-term disability policy language, the internal ERISA claims process, and your burden of proof to establish your entitlement to long-term disability benefits, can place significant hurdles in your path. If you have a choice, Cavey & Barrett strongly recommend that you purchase a private long-term disability policy that is tailored to your specific needs and will let you quickly go into state court to seek the long-term disability benefits that are due and owing to you.
Answering these broad-based questions isn’t easy. Help is a phone call away. You can contact Nancy Cavey, an experienced long-term disability attorney at 727-894-3188.