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Despite the easy win, this ERISA case has important lessons

On Behalf of | Jan 31, 2024 | ERISA

Ideally, you should get through life without having to think about long-term disability and the often arduous ERISA application process. Worst case scenario, you should only have to deal with this once. So, unless you’re an avid reader of this blog, it’s understandable that you wouldn’t be aware of the veritable minefield of potential missteps and mistakes laying in wait for applicants. In the following case, which was a slam-dunk win for the plaintiff, there are nevertheless a couple tips that might have saved the plaintiff from appearing in court.

If possible, apply for ERISA benefits before leaving your job

In Weisman v. The Guardian Life Ins. Co. of Am., Guardian argued that the plaintiff was not eligible for long-term benefits, because he waited until after leaving his job to apply. As the court pointed out, under the plaintiff’s plan, the plaintiff was indeed eligible as he became disabled while he was employed. The timing of his application was therefore irrelevant.

While the plaintiff was ultimately successful in fending off that reason for denial, applying for long-term benefits while he was still employed may have saved him from going to court.

Have exhaustive medical treatment documentation ready

This was an unusual situation. The plaintiff was not yet under the regular care of a doctor until after he applied for long-term benefits. Guardian argued that a self-diagnosis and self-treatment did not satisfy plan requirements that applicants must be under a doctor’s care before applying for benefits.

However, the plaintiff is a doctor himself and the court determined that he was suitably qualified to diagnose and treat himself up until the point when he required additional care. The court also noted, again, that any applicant who becomes disabled while still employed is eligible for benefits. The court added that even if the applicant isn’t a doctor, the “insured’s subjective assessment of his own symptoms are relevant as a general matter to determining disability.”

Most of us are not doctors and would therefore have to work a little harder to win this debate in court. However, the underlying lesson here is that everyday folks should, whenever possible, see a qualified doctor and have a definitive diagnosis before submitting an ERISA application. While it’s not a deal-breaker, you should include exhaustive supporting medical documentation with your initial application for a (hopefully) smoother path to benefits.

One of the most common reasons for denied ERISA benefits, not to mention Social Security Disability benefits, is that crucial information or documentation was missing from the application. Most doctors should be familiar with the necessary documentation that insurance providers require, but if there’s any doubt, consulting an ERISA attorney may save you a drawn out and stressful appeal after an initial rejection.