Filing ERISA Disability Claim
Filing a ERISA Disability claim under an ERISA (Employee Retirement Income Security Act of 1974)-qualified policy can be complicated. Although every employer provided long term disability plan must comply with ERISA, the law allows a wide range of flexibility in participant requirements. (An employee insured by an ERISA policy is called a “plan participant.”) To collect any compensation from your policy, you will need to provide significant evidence to support your ERISA disability claim. Your insurance company may deny your claim if you do not provide enough evidence.
In order to quickly and efficiently deal with an ERISA disability claim, you should contact an experienced disability attorney. Our lawyers at Uscher, Quiat, Uscher & Russo, P.C. will guide you through the complex process and help you collect the evidence necessary to have your claim successfully processed.
What Do You Have To Prove?
Although every ERISA disability insurance policy is slightly different, you must prove to any insurance company that you are disabled. You must be able to prove all of the following with objective evidence:
- The date you became disabled.
- The last date you worked (LDW).
- You have a medical condition that results in disability.
- You are unable to perform duties of your job.
You must show each of these elements with objective proof. Objective proof is based on facts, observation, and measurement. This is different than subjective proof, such as a personal description of your symptoms. Although you will be required to tell your doctor about your subjective symptoms, the insurance company is primarily interested in objective tests and other evidence.
Proving Disability Date and Last Date Worked
Your doctor and employer should keep records of relevant dates; however, it is your responsibility to obtain those records for the insurance company. You can prove the onset of your disability by providing doctor’s office notes indicating a specific date at which your doctor concluded that your condition became so severe that you could no longer work. If you do not have such specific records, you may have to prove with other objective evidence that you were unable to work as of a certain date.
The last date you worked will be recorded by your employer. You may have access to those records through your human resources department or through your immediate supervisor. If the date does not match your onset of disability date, you may have to provide additional evidence to your insurance company regarding why your last date worked differs.
To prove the date you became disabled and the medical conditions that resulted in disability, you must have objective medical evidence. Every insurance company will evaluate that evidence differently; however, there are some generally accepted tests and observable factual evidence that are universally accepted.
In general, any of the following are accepted as objective medical evidence:
- Radiological tests (x-rays, CAT scans, MRIs).
- Nerve conduction tests.
- Blood tests and other laboratory analyses.
- Psychological tests conducted by licensed psychologists and psychiatrists.
Often, office notes from doctors are not sufficient objective medical evidence. Doctors document your subjective complaints and take those into account to treat you. However, your insurance company will not consider subjective evidence or medical evidence that is based on subjective complaints. You must have a record of objective evidence in order to prove that you are disabled.
If you do not have enough objective medical evidence, your insurance company may deny your claim or send you to another doctor. If you are sent to another doctor for an independent medical evaluation (IME), you must be completely honest about your conditions. The doctor will likely conduct several tests and collect subjective data as well. The doctor will evaluate whether he or she thinks you are malingering, or exaggerating your conditions. The IME performed by the doctor will provide some of the most influential medical evidence to your insurance company, so it is essential that you attend and participate fully in the evaluation.
In order to prove your last date worked and that you are unable to perform job duties, you must provide your insurance company with vocational evidence. Vocational evidence may be obtained from your employer, industry standards, witness statements, and doctors. Your employer can easily provide information regarding your last date worked and a description of your job duties. Once those duties are established, it is your responsibility to prove that you are unable to perform them. If the duties provided by your employer are not complete, you may need to supplement your actual job description with industry standards.
Your doctor can provide an assessment of your functional capacity in order to show that you are unable to perform your job duties. Some of the objective medical tests that your doctor performs can be utilized to show that you are incapable of performing job duties. However, your doctor may also complete a functional capacity evaluation form, which can be provided by your insurance company, to fully describe your abilities an inabilities.
Whether you are just beginning your ERISA disability application or you’ve been denied, you have a long road ahead of you. Not only do you have to make an initial proof of disability, but you must also provide information on a continuous basis. Let us help you navigate the complex process of applying for or appealing an ERISA disability claim. Call one of our experienced disability attorneys at Uscher, Quiat, Uscher & Russo, P.C. today at 1-800-797-5575.