Disability Denials
If your disability insurance policy was provided by a private employer, your policy and any claim filed thereunder is likely governed by a federal law called ERISA.
If you have found yourself in the unfortunate position of having to apply for disability benefits under your ERISA governed policy, you might encounter a complicated and frustrating process when trying to obtain benefits. Not surprisingly, disability insurance claims are often denied for a variety of reasons, not all of which are valid or reasonable. So, what should you do when your insurance company denies your claim for short term or long-term disability benefits?
The Employee Retirement Income and Security Act (“ERISA”) was originally enacted to protect employees covered under employee welfare benefit plans. This includes employees that file for disability insurance benefits under their employer sponsored insurance policies. ERISA also requires the plan administrator to provide a uniform process for appealing the denial of claims.
This means that insurance companies who provide disability insurance through private employers must adhere to the rules and procedures set forth by ERISA in administering insurance plans.
Victor Peña Law Will Fight For You
If you are unable to work and are relying on income from your disability benefits to pay the bills, it is essential that you consult with a disability insurance lawyer who can protect your rights and who can give you the best chance at obtaining a result that will enable you to continue to provide for yourself and your family.
Victor Peña Law specializes in disability claims and ERISA appeals. We will bring in our own medical and vocational experts to review your medical and work history and help ensure that you present the best evidence for your appeal. In the event that your appeal is denied, we will file suit against the insurance company and demand that the decision to deny your appeal be overturned.
For a free consultation, call Victor Peña Law at (954) 828-0592 or contact us online to receive a call the same day.
ERISA And Disability Insurance
While ERISA mandates insurance companies to provide a full and fair review of each claim, ERISA also gives insurance companies an unfair advantage over disability claimants. If you have filed a claim for disability insurance and it was denied, you have the right by law to file an appeal with the insurance company. Not only is this your right, but you are also required to file an appeal to preserve any legal rights to file a lawsuit. Failure to timely submit the appeal to the insurance company would cause you to lose your right to file a lawsuit against the insurance company to recover your disability benefits.
ERISA appeal must be reviewed and decided by someone who did not make the initial decision to deny your claim.
It is important that any ERISA appeal is done with extreme care and is prepared thoroughly. In the event that your appeal is denied, and you decide to sue the insurance company, the court most likely will only look at the evidence presented in the appeal. No new information will be considered by the court. A skilled and experienced disability claims lawyer will be able to ensure that your appeal preserves all relevant evidence which may later be examined by the court.
ERISA Appeals Process
The appeals process will start after your disability claim has been denied. Your insurance company will most likely send a letter to you outlining the reasons for the denial. They must also cite the particular terms of the policy that they are relying on to deny your claim. Finally, the letter must alert you about your right to appeal and it must describe the appeals process.
Under ERISA law, the insurance company must give you 180 days from the date of denial to file an appeal. The insurance company has 45 days to respond. They can also request two 30-day extensions if they have proper justification. By law, the insurance company must provide you with the complete case file regarding your claim free of charge. Your file might be hundreds or even thousands of pages long and contain complex medical documents that are not easily understood by non-medical professionals.
During the appeals process, you are allowed to submit documents and reports to support your claim. Don’t expect the insurance company to tell you which documents and evidence are necessary to get your claim approved though. Since there is a limited time to file an appeal, consulting with an experienced disability lawyer early in the process is recommended in order to give you ample time to gather all of the evidence that will most likely produce a claim approval.
In certain cases, the insurance company will request that you be evaluated by an independent third-party doctor to determine if your condition prevents you from working. Typically, these doctors are not really independent, but rather have a close working relationship with the insurance company. Submitting to the insurance company’s independent doctor is not optional. The doctor will draft a report which will be included in the appeal.
Similarly, you will have the option of seeing your own doctor to help prove your claim. Your own doctor’s opinion could be especially important to procure since the third-party doctor might suggest that you are not disabled or might downplay the extent of your disability.
For additional support, it is common practice for claimants to include a personal statement in addition to letters from co-workers relating to the disability. Moreover, it makes sense to keep a pain log detailing your level of discomfort over the course of your disability. Evidencing your disability goes a long way in these cases.
Once the insurance company has received all of your appeal evidence, a decision will be made. The standard for deciding appeals is whether or not the insurance company acted reasonably in denying your claim. It is important to remember that the person deciding your appeal will most likely be an employee of the insurance company. While this person is bound to exercise a certain level of fairness, they ultimately work for the insurance company. They are not in your corner.
In the event that your appeal is denied, you have the option of filing suit against the insurance company and taking the matter to court.
Hiring A Lawyer to Handle Your Disability Insurance Claim
It is not uncommon for the initial application to be denied. If this happens, you may have a right to appeal that decision. However, once a claim is denied the processing of appealing if the claim is governed by ERISA can be exhaustive. It is always better to make sure the application is handled properly by an experienced professional rather than fighting to fix problems in an improperly completed claim application.
Victor Peña Law – The ERISA Disability Law Firm
Attorney Victor Peña has extensive experience handling ERISA lawsuits against every major disability insurance company. He has helped claimants recovery millions of dollars in disability benefits making a recovery in 99% of lawsuits filed. We have helped clients nationwide.
Almost every aspect of your case can be handled by phone, video conferencing, or mail – making it easy to work with us. No matter where you are located within the United States, our firm will be able to help you get the disability benefits that you are entitled to.
In the event that your benefits are denied, don’t lose hope. We can give you the peace of mind in knowing that someone is fighting for your rights. The sooner in the process that our firm is retained, the faster that we can help get you your payments. Call Victor Peña Law at (954) 828-0592 or contact us online for a free consultation today.
What makes ERISA disability lawsuits difficult?
Many claimants don’t realize the challenges they or their lawyer will be facing if an ERISA disability claim has to be litigated. It is crucial to understand that a case is often won or lost before a lawsuit is even filed.
The main challenges in an ERISA lawsuit can be summed up as follows:
No new evidence can be submitted
There is no Live Testimony
No Jury Trial
The Court must defer to the Insurance Company
No Punitive damages
You can only recover back benefits owed
The standard of review is pro-insurance
There is no guarantee of Attorneys Fees
No New Evidence or Testimony can be submitted
By the time a lawsuit is filed, the administrative record on an ERISA claim is closed. This means that no new evidence can be submitted to supplement the file. The final appeal submitted to the insurance company was your last chance to strengthen you case with additional medical evidence in support of your disability claim.
In reviewing your case, the court will review only the information available in your administrative record to determine if your claim was wrongfully terminated. You will not be allowed to testify, so a judge will not hear your story. None of your doctors will be able to testify to support your claim and none of the insurance company’s doctors can be questioned on the stand. Your lawyer will not be able to take a deposition or cross examen in court the insurance company employee who made the decision to deny the claim.
All of this means that you will be at a big disadvantage. Hiring an experienced lawyer to prepare a strong appeal before the final decision is made will help give you a better chance.
Attorney Victor Peña accepts cases where he has not prepared the appeal although we are stuck with the evidence already contained in the record. It is possible to still attain a good outcome for a client if we can prove the insurance company’s review was unreasonable.
You Have No Right to a Jury Trial
Having a jury trial could greatly benefit a claimant, if you had a right to one. However, ERISA disability lawsuits do not come with the right to a jury trial. While this means you do not get the benefits of a jury trial there are also a few advantages to not having a jury trial. Trial dates can be set much sooner and looking at a Judge’s past rulings on other ERISA claims can give a good idea for how the Judge might rule in your pending lawsuit. This also means that the costs of litigation are much less that it would be with a jury trial.
Remedies allowed in ERISA disability lawsuits
Claimants are often disappointed when they learn what remedies are available to them if an insurance company loses on an ERISA disability claim. Particularly where the insurance company acted in a manner that, were the claim governed by state law, would subject the insurance company to bad faith damages. Bad faith damages are a familiar concept to many because they are often a source of large payouts in insurance lawsuits. However, these damages are not available in ERISA lawsuits.
When a lawsuit is filed, the remedy being sought is a reinstatement of the claim and an order for the insurance company to pay all back benefits owed to the claimant plus attorney’s fees. However, in about half of ERISA lawsuits the court will “remand” the case back to the insurance company with an order that the insurance company perform another review of the claim. This leaves the claimant waiting for months for the insurance company to perform another review of the claim. Often, the decision ends up being the same. During all this time, claimants suffer many economic losses such as credit score drops, car repossessions and loss of their homes. Unfortunately, the insurance company cannot be held responsible for these losses. Moreover, no matter how bad or unreasonable the claim denial, there is no right to punitive or bad faith damages. Attorney’s fees can be awarded but they are at the discretion of the judge if the judge determines that the claimant had “some success on the merits of the case”.
The Standard of Review
Perhaps the most difficult aspect of an ERISA disability lawsuit is the standard of review that a federal court will apply when reviewing a disability denial. The best standard of review for a claimant is the de-novo review. This means that a judge will conduct an independent review of the entire administrative record and make a decision as to whether the claimant is entitled to disability benefits. The worst standard of review, and most common, is the arbitrary and capricious standard of review. This standard goes beyond the de-novo standard and typically allows a judge to reverse an insurance company’s decision only if the judge finds the insurance company acted unreasonably. The judge must decide which standard applies and usually this depends on whether the disability policy contains a discretionary clause giving the insurance company discretion to interpret the terms of the plan and to determine eligibility for benefits. Several states have made discretionary clauses illegal and it is important that every case is reviewed for an argument to invalidate the discretionary clause.