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Who decides if you are disabled when you seek ERISA benefits?

On Behalf of | Apr 22, 2022 | ERISA

Insurance never seems very important until you need to make a claim. Your employer offering a company-sponsored disability policy was likely less of a factor in your decision to accept the job than the salary, paid time off and work schedule offered.

However, once you have a disabling medical condition and can’t work, those benefits will suddenly become incredibly important. The Employee Retirement Income Security Act of 1974 (ERISA) is a federal statute that governs employer-sponsored health, life and disability insurance benefits.

ERISA helps protect you when you need benefits and extends certain rights during the application process for such benefits, like the right to appeal a denial of benefits that you believe is unfair, and the right to see the evidence upon which the denial of benefits is based. Obviously, you can only be eligible for disability compensation if you have a disabling medical condition, which must result in restrictions and limitations which preclude you from doing your work. Simply having a diagnosis of an injury or illness which could be disabling is not enough. You must also show how that diagnosed condition actually limits your ability to do your job. For example, you may have a broken leg which limits your ability to walk, but if you have a sedentary “desk job” you may not qualify for benefits, since walking is not a substantial requirement of a sedentary job. If your job requires you to walk continuously throughout the course of the work day, then a broken leg may very well preclude you from doing that job. The disabling medical condition must be matched against the job requirements you have in order to prove an entitlement to disability benefits; one or the other alone will not be sufficient, so it is not just a medical question, it is also a vocational question.

Who gets to decide whether or not you have a disability?

The Employer may have a say

but frequently has delegated that power to an insurance company who has more expertise in evaluating medical restrictions and limitations. Since the insurance company is usually the one who pays the benefits under the group policy purchased by your employer, it is the insurer who typically must be convinced of your entitlement to benefits.

When you apply for long-term disability benefits, you will need to provide the insurance company with documentation about your physical or psychiatric condition which demonstrates the existence of a medical condition which restricts and limits your ability to work. These typically will take the form of medical records, tests results, and communications from your treating doctors which explains the basis for the diagnosis, and the reason that diagnosis restricts and limits your ability to work. Adequate records of medical tests and letters from physicians regarding the severity of your condition and its impact on your life are essential when you file for benefits.

The plan administrator (usually the insurance company) who manages and funds the long-term disability policy offered through your employer will review the evidence that you submit based on the insurance company’s policies and then determine if you qualify for disability benefits based on the documentation provided. If they deny your claim, you have the right to an internal administrative appeal within the insurance company, and you have the right to see the evidence which the insurance company claims supports the denial of benefits. 

Eventually, a judge could also have a say.

ERISA benefits claims often find their way to civil court, once all internal appeals have been exhausted. But before you have a right to go to court, you must first appeal the denial of benefits internally. This is called “exhausting your administrative remedies”. If you do not follow this process, you will not be successful in court. You must comply with the appeal instructions in your insurance policy plan documents. There is a deadline for filing an administrative (internal) appeal, so you will need to act quickly.

Only if all internal appeals are unsuccessful will you need to go to court, where a judge may have to review the documentation you provided during the administrative appeal process, prior to filing a lawsuit. It is critical to understand that in many cases, you will only be allowed to rely on the evidence which you previously submitted to the insurance company during the administrative appeal process. In these situations it is essential that you put all your supporting evidence into the record in support of your internal appeals to the insurance company. If you wait until you get to court to offer evidence in support of your claim which was not provided to the insurance company before the lawsuit was filed, the judge may not allow you to offer that evidence in court. The point is: you must do everything you can to win at the administrative appeal level, before you file a lawsuit, because the outcome of the lawsuit will be determined on the evidence you previously submitted to the insurance company, so make sure all your evidence has been provided as part of the administrative appeal to the insurance company. Waiting until you get to court to “bring out the big guns” is a serious mistake in an ERISA litigation.

The same is true for when you hire a lawyer to assist. If you wait until you get to court before you hire a lawyer, that lawyer will be limited by the evidence you previously submitted to the insurance company and will have little opportunity to present any other evidence. These claims are won and lost at the administrative appeal level, so if you intend to hire a lawyer to help you pursue your claim, do it during the administrative appeal process when the lawyer has the ability to identify the evidence you need and make sure it is in the record. If you wait until you get to court, you will not get the benefit you might have had from consulting a lawyer about what evidence needs to be in the record in order to win the claim.

Having the right information and support when filing an ERISA long-term disability claim will substantially improve your chances of getting those benefits approved and paid. A knowledgeable ERISA lawyer will help you identity and obtain the evidence you need during the administrative appeal process to prove your case.

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