What Is ERISA?

Were your ERISA disability benefits denied in California? An attorney can help.

Most of the life, health and disability policies issued through employers in the United States are governed by the Employee Retirement Income Security Act of 1974 (“ERISA”), a federal statute that protects employee benefits by imposing minimum standards on employers/‌ERISA administrators.

ERISA requires plans to provide participants with plan information including important information about plan features and funding; provides fiduciary responsibilities for those who manage and control plan assets; requires plans to establish a grievance and appeals process for participants to get benefits from their plans; and gives participants the right to sue for benefits and breaches of fiduciary duty.

ERISA involves a complex area of law that can be difficult for many people to understand. For that reason, some employers and insurance companies take advantage of disabled workers and improperly deny their claims. If you are interested in receiving ERISA benefits but aren’t sure if you’re eligible, or filed for ERISA benefits and your claim was wrongfully denied, a California ERISA attorney can help you.

Who Is Eligible For ERISA Benefits?

Those who are approved for social security benefits or private benefits may be rejected under ERISA. Not all candidates are eligible, and the full list of eligibility requirements is exhaustive.

ERISA applies to private-sector companies that offer pension plans to employees. Regardless of how your employer has structured his or her business (limited liability corporation, S-corporation, C-corporation, or other) it is covered by ERISA as long as it is a private entity. ERISA was enacted to ensure that the benefits an employee has been promised, that are part of their retirement or severance package, are provided as they were originally intended to be.

Why Was My ERISA Disability Claim Denied?

Many people believe they are eligible for ERISA benefits, but are still denied. It can be difficult to understand without the insight of a lawyer. Disability claims that would ordinarily be approved under private disability or social security disability are often rejected in the ERISA system. The following list are common reasons why claimants have been denied ERISA benefits:

Failure to provide medical documentation or evidence that proves your disability
Incomplete information or errors in the claim information
Failure to meet filing deadlines
Pre-existing medical conditions
Self-reported symptoms (not properly documented with medical professionals)
Out of scope treatment (medical care not authorized or out of protocol)
Contradicting evidence from social media or private investigators
Employability in a different occupation
Specific exclusions from your individual policy

These are still more reasons why an ERISA disability claim can be denied in California. This process can be exhaustive, and can be a lot for an individual to handle without the help of a qualified attorney. If your ERISA claim was denied in California, waste no time and contact a lawyer as soon as you can.

Can I Appeal A Denied ERISA Claim?

Was your ERISA disability claim denied in California? There’s still hope. One of the most helpful aspects of working with an ERISA attorney is that they can help you appeal your wrongfully denied claim and resubmit a stronger application. If you believe that your ERISA disability claim was wrongfully denied, an attorney will advise you whether or not appealing the decision is the right course of action to take, depending on the specifics of your situation.

If your attorney advises that you submit an appeal, they will walk you through this process and ensure that every important deadline is met. Your attorney will then help you strengthen your claim. This is often done by fixing any errors, adding any supporting documentation such as medical information, and will make sure all fields are complete with the strongest information possible to prove your right to these benefits.

ERISA involves mandatory administrative appeals and strict deadlines, so it is imperative that you know your rights and swiftly hire an ERISA attorney. If you do not follow the proper appeal procedures, you could lose your right to sue your employer and/or the insurance company that administers the claim.

Schedule A Free Consultation With An ERISA Lawyer If Your Disability Claim Was Denied

If you or a loved one have become disabled, getting the benefits you deserve is crucial. Contact McKennon Law Group PC with any initial questions you have about ERISA benefits, even if you’ve been denied.

We offer an initial consultation for any California resident in need of guidance regarding ERISA disability claims. Your initial case evaluation with McKennon Law Group PC is free of charge, and comes at no risk or obligation to you.

Have you lost your job while on long term disability benefits? When a worker in California becomes injured, they can file a claim with their insurance company, and, after a potentially lengthy process, the insurance company may start to pay long term disability or accidental death and dismemberment benefits.

California residents who receive long term disability benefits receive them through their employers or external policies they have purchased. Obtaining long term disability benefits is a process that falls under workers’ compensation benefits. Workers’ compensation laws protect those who have become injured or disabled while working at their jobs.

Under many disability plans, you can receive benefits until you retire as long as you are still disabled and then able to work. Since many California residents receive their long term disability benefits through their employer, what happens when they lose their jobs? If an insurance company is responsible for providing your long term disability payments, termination of employment won’t necessarily stop your payments. It’s rare, but it is possible. In many cases, a disabled individual will continue to be given long term disability benefits if they are employed or not.

If you find yourself in this dire situation, you can still file for long term disability benefits with the help of a California lawyer. Maintaining these benefits are important to future, health, and wellbeing, so it’s important that you take the first step and contact a lawyer if you lose your benefits due to termination.

What Causes Someone To Lose Long Term Benefits?

There are many ways in which an individual can lose long term benefits. One factor to consider is that you must continue to get medical care for your disability condition as you receive benefits. If you fail to make your doctor’s appointments, you may lose your long term disability benefits. If you lose your health insurance, it may become increasingly difficult to get the medical care you need. When this happens, some people fail to get new health insurance, causing them to skip doctor’s appointments and diagnostic tests, causing them to lose their benefits.

How Can A California Lawyer Help With Long Term Disability Benefits?

You still may be eligible to apply for long term disability benefits even after you lose your job. If you are unsure of your eligibility status, you should consult with a lawyer as soon as possible, tell them the details of your employment, and listen to their legal advice.

Your lawyer will help you in a multitude of ways. Many California residents don’t know that the onset date of your disability is more important than the date that you stopped working at a certain job. For example, if you were injured on the job and ceased employment a year later, you may be still eligible for disability benefits because the injury occurred before your employment ended. Your lawyer will help source, compile, and assess certain important documentation that proves that your injury date and termination date occurred at different times. Evidence that proves that you became disabled while still under active employment will be crucial for securing your long term disability benefits in the future.

In the unfortunate event that your long term disability benefits are wrongfully denied, your lawyer can help you file and submit an appeal to this decision as well. For example, when an insurer terminates benefits without signs of the insured’s improvement, there are often other improprieties that, when viewed as a whole, will compel a court to reverse a termination of benefits. This is why it is important to work with a lawyer who understands nuances of the law such as these.

Having an attorney present during all of these proceedings is absolutely integral to the success of your case. Long term disability benefits are a lifeline for many injured victims and, without them, you could lose income you desperately need to get by.

Call Today For A Free Consultation With McKennon Law Group PC About Long Term Disability Benefits

It’s incredibly important to work with a California attorney who understands the intricacies of disability law. Without your long term disability benefits, your life could change for the worse. If you’ve lost your job while receiving long term disability benefits, you need to act fast. With the help of an attorney, you can file an appeal and resubmit your claim to get the benefits you deserve.

Schedule a free, no-risk case evaluation with McKennon Law Group PC as soon as possible after losing your long term disability benefits. Your initial consultation is completely free of charge, and comes at no obligation to you.

California law imposes an implied duty of good faith and fair dealing on every insurance policy, based on fundamental principles of fairness. Everyone owes a duty of care to others and, when that breach occurs, the at-fault party must be held accountable for any damage they’ve caused.

This duty of good faith extends beyond just people. Businesses, companies, hospitals, educational institutions, and other organizations must operate in a duty of good faith as well. Insurers are required to act in a fair and reasonable manner as well. This duty of care prohibits them from acting or failing to act in any way that would deprive policyholders of their owed insurance benefits.

When an insurer fails to act in accordance with the terms and conditions laid out in a contract, a breach of contract has occurred. This is a different situation than a bad faith insurance claim, but both incidents should be taken seriously. If you’ve been a victim of an insurance breach of contract or a bad faith insurance claim, you need the help of experienced legal counsel as soon as possible.

What Is A Bad Faith Insurance Claim?

Bad faith occurs when an insurance company fails to fulfill the obligation it has made to its clients, and works with them in an unfair or unlawful way. Sometimes, an insurance company will refuse to pay a policyholder’s claim, even when the claim is legitimate and the policyholder does in fact have a right to that claim.

If an insurance company acts unreasonable or without proper cause, this is often considered operating in bad faith. It’s a much more broad term and concept than a breach of contract, which denotes that a specific term of your contract was not upheld.

How Is A Breach Of Contract Of Bad Faith Insurance Claim Differentiated In Court?

Both breaches of contracts and bad faith insurance claims deal with similar kinds of behavior. Both relate to insurance companies who have failed to fulfill their obligations to their policy holding customers. But a key differentiating factor between the two is determining where the insurance company’s obligation comes from.

Let’s use car insurance as an example. For the most part, the majority of an insurer’s legal obligations to their policyholders come from insurance policies and any riders that are added to the original policy. The insurance company’s duties, as laid out in the insurance policy, are governed by the principles of California state contract law. This set of laws is used as a basis to enforce legal contracts, and is used to differentiate a breach of contract from a bad faith insurance claim.

Bad faith insurance claims, on the other hand, are rooted in the duty of good faith that’s placed upon every resident of California. State courts, under common law and other statutory requirements, require insurance companies to uphold a covenant of fair dealing with every policyholder. Common law and statutory requirements govern bad faith insurance dealings, and lay out the framework for how these findings are defined and penalized.

Do I Need A Lawyer If Breach Of Contract or Bad Faith Has Occurred?

Any time you’ve been a victim of someone’s negligence, recklessness, or bad faith, you have the right to contact a lawyer about what you have experienced. It can seem tough to stand up against a negligent insurance company, especially since they have their own lawyers and the funds to defend themselves aggressively. That’s why it’s imperative that you contact experienced legal counsel as soon as you’ve been wronged by your insurance company.

With the help of a legal representative such as a lawyer, you can fight back against these big insurance companies and have your side of the story told in court. Your attorney will defend you against the insurer, and will stop at nothing to ensure you get the justice and compensation that’s rightfully owed to you.

Contact McKennon Law Group PC If You’ve Been A Victim Of Bad Faith Insurance Or A Breach Of Contract

McKennon Law Group PC offers a free, no-risk case evaluation to any California resident who has been victimized by their insurance company. The importance of working with smart legal counsel dring this time cannot be overstated. WIthout the help of an attorney, it can feel impossible to have your side of the story heard and to stand up against these insurance companies.

Your initial case consultation with McKennon Law Group PC is free of charge and comes at no obligation to you. The sooner you call, the sooner you get advice about standing up to your insurance company.

What Is Negligence?

Negligence is the term that refers to an individual’s failure to behave with the level of care that someone of ordinary prudence would have exercised under the same circumstances. The behavior usually consists of actions, but can also consist of omissions when there is some duty to act

Simply put, negligence is a legal concept under which all people are held responsible for their actions or their lack of action. We all owe others a basic duty of care. When someone’s behavior or actions don’t meet that basic duty, negligence has occurred. This is the area of law that proves why a negligent person should be held accountable and financially responsible for any injuries that occurred as a result of their carelessness.

Negligence plays a key role in personal injury law, and many California residents will find themselves a victim of someone else’s negligence at some point. For that very reason, it’s important to have an understanding of the law of negligence in California.

What Are The Elements Of Negligence Under California Law?

There are four basic elements of negligence under California state law: duty, breach, causation, and damages.

Duty demonstrates the expectation to use reasonable care with regard to others, i.e, “ a duty of care”. This duty is covered by the law. For example, shopkeepers owe a duty of reasonable care to those who patronize their stores. If there are tripping and slipping hazards on the floor, this duty of care has been breached. All drivers owe a duty of care to others on the road as well. If one driver gets behind the wheel while intoxicated and puts others at risk, they’ve breached their duty of care. This “breach” is the term that describes the wrongful conduct/unlawful act.

Causation is broken down into legal and factual causation. Causation is a very detailed, nuanced concept that could be meticulously explained in hundreds of ways. A simple summary of causation is the relationship between someone’s breach of care and the damage that occurred. If a shopkeeper failed to mop up a slipper spill on the ground, and you fell and broke your leg, you have causation which can be used in court to demonstrate the shopkeeper’s negligence.

Damages are less complicated than breach and causation. Damages include the cost of your medical care, your lost wages and diminished future earnings, your pain and suffering, and damages to your property. Anything you’ve had to spend – your time, money, emotional labor – due to someone else’s negligence, is referred to as damages.

There are many landmark California court cases, such as Lee v. West Coast Life Insurance Company, that have grappled with the concept of negligence in order to pay out damages to those who’ve been injured. If you have suffered an injury and have reason to believe someone breached a duty of care, causing the injury to occur, contact a personal injury lawyer as soon as possible.

What Is The Statute Of Limitations For Negligence In California?

Under California state law, the statute of limitations for negligence depends on the specific circumstances and entails of the case. For a personal injury case specifically, there is a two year statute of limitations. This means, an individual who has suffered an injury due to someone else’s negligence, carelessness or recklessness has two years from the date of the incident to seek damages via filing a personal injury claim.

How Much Does It Cost To Speak With A Personal Injury Lawyer About Negligence?

At McKennon Law Group PC, the vast majority of our clients retain us on a contingency fee basis. This means that our fee is calculated as a percentage of the total recovery we achieve for our client. Some specific cases are charged hourly fees, and in certain rare circumstances, we can offer a fixed flat rate.

We offer a free, no-obligation phone consultation to any California resident who has been injured due to someone’s negligence. We offer three fee options so that every person who seeks our help can have a range of options available that suits them.

Schedule Your Free Personal Injury Consultation With McKennon Law Group PC Today

If you are stuck paying medical bills for an injury that someone else caused, are out of work and don’t know what to do, you have the right to hold this negligent person accountable in a California state court. You have the right to seek compensation. Our attorneys will build a strong personal injury case that highlights that person’s negligence or breach of care, demonstrating causation, and defend your right to damages.

Call McKennon Law Group PC today to schedule your complimentary case evaluation.

In California, if an insurance company is not handling your claim in good faith, what are your rights? What steps can you take? Can or should you sue the insurance company? The first step you should take is scheduling a consultation with a California bad faith insurance attorney.

We all pay a substantial amount for insurance. If you are injured by a negligent driver, or if a loved one dies accidentally, you probably expect your insurance company to approve your personal injury or accidental death claim quickly, and most insurance companies will.

The policy you hold is a promise from your insurance provider to be there with coverage when coverage is needed. When you pay for a policy, the company is legally obligated to provide coverage. It is also obligated to negotiate with you and resolve in good faith any claim you make.

Don’t allow your insurance company to take advantage of you or to operate in bad faith when it handles your claim. By law, an insurance company cannot avoid its obligation to make a payout on your claim or to offer a sound and legitimate reason for denying the claim.

How Is Bad Faith Defined?

If your insurance company does not take its legal obligation to you seriously, you could have sufficient grounds for a lawsuit alleging insurance bad faith. A simple denial of your claim is not enough. A bad faith lawsuit must be based on an insurance company’s specific acts or failures.

In California, if an insurance provider does not meet its responsibility to you, discuss your case promptly with a California bad faith insurance lawyer. Below are listed some – but not all – of the reasons why an insurance company may be targeted with a lawsuit that claims bad faith:

failure to investigate or negotiate your claim in good faith
failure to share with you important information
failure to provide an explanation for a claim’s denial
failure to pay off a claim without even investigating it
failure to offer a reasonable settlement in a case where the liability is obvious
failure to act on a claim within a reasonable time-frame
offering a settlement amount that’s far less than the value of your claim

Bad faith insurance practices include prolonging a claim investigation needlessly, coercing or intimidating you into taking an insufficient payout amount, or rejecting your claim for a fabricated or disingenuous reason.

Will a Letter to the Insurance Company Help?

A straightforward disagreement over your claim’s value doesn’t mean that you are dealing with bad faith, but if you’re offered an unreasonably low settlement amount with no explanation, or if you’ve been deceived by the company, you’re probably a victim of bad faith insurance practices.

Sending the insurance company a letter – or asking your attorney to send a letter – might be enough to generate some action from the company. When an insurance company knows that you have taken the matter to an attorney, the company is more likely to begin treating you right.

The potential for legal action may compel an insurance company to make a settlement offer that’s reasonable, because if you prevail in court with a bad faith claim, the company may have to pay your attorney’s fees and additional damages over and above the original claim amount.

How Can You Help Your Bad Faith Case?

If your case goes to court, you and your insurance attorney will have to offer specific instances of an insurance company’s bad faith. You can help your case by making copies of the pertinent insurance documents and copies of any letters or emails to or from the insurance company.

Also, be sure to maintain a record of any conversations with the company. Take notes that include the time, date, and the name and job title of the individual who spoke with you.

If your case goes to court, you and your insurance attorney will have to prove that by denying your claim, the insurance company was not merely making an honest mistake but was negligent or was intentionally acting in bad faith.

How Will Your Attorney Prove Your Bad Faith Claim?

A California bad faith insurance attorney may ask your insurance company for the documents and records related to your claim and for other documents detailing the company’s procedures and policies.

The insurance adjuster or another representative of the company may be subpoenaed for a deposition or to testify in a court hearing. In certain cases, an insurance claims attorney may ask an insurance expert to make a statement or testify about insurance industry practices.

If the company did not comply with its own practices, procedures, and guidelines, and if your insurance claims lawyer can prove it, your bad faith insurance lawsuit will probably prevail.

When Should You Speak to an Insurance Claims Attorney?

If you’re not sure, how can you find out if you are dealing with bad faith insurance practices? You should send a complaint to the California Department of Insurance, which can impose both administrative penalties and in some cases bring criminal charges against insurance companies.

But you must consult a California bad faith insurance lawyer to know if you have sufficient grounds for a bad faith lawsuit and to know if the denial of your claim can be overturned. Schedule a consultation as soon as you suspect that you are dealing with insurance bad faith.

As mentioned above, in the State of California, a plaintiff who succeeds with a bad faith lawsuit may recover attorney fees in addition to a judgment that orders the insurance company to pay the original claim. Your first consultation with an attorney is free and entails no obligation.

Don’t Be a Victim Twice

If you’ve made a claim against an insurance policy, you may be at a difficult point in your life. You may have lost a loved one accidentally, or you may have sustained a severe personal injury. You should not have to be victimized a second time by an insurance company’s bad faith.

As a policyholder, you have the right to be dealt with in good faith by your insurance company. Most California insurance companies will do that, but if you aren’t being dealt with in good faith, speak about your legal rights and options with an insurance attorney as soon as possible.

Insurance companies will go to great lengths to avoid paying claims. One way in which they do that is by trying to shoehorn the facts of the claim into a particular policy exclusion. One of their favorite exclusions is the pre-existing condition exclusion. A good example of this is found in Gustafson-Feis v. Reliance Standard Life Insurance Company, 535 F.Supp.3d 1076 (W.D. Wash. 2021). In Gustafson-Feis, the plan participant/insured, Lisa Gustafson-Feis, suffered a labral tear in her hip area during a work trip to China. She applied for long-term disability (“LTD”) benefits through her company-sponsored ERISA plan, which was insured by Reliance Standard. Reliance Standard denied her claim contending that coverage was precluded by the policy’s pre-existing condition exclusion that is typical in LTD policies. It contended that Gustafson-Feis’s injuries were caused by a pre-existing condition because the insured, although otherwise fully recovered from a prior vehicle-accident injury to her spine and pelvic region that occurred approximately two years before, was still taking pain medication for that injury. The court determined that Reliance Standard failed to demonstrate that the plan participant’s labral tear and ensuing disabling pain represented continued progression of her prior serious hip injury (instead of a new injury) and thus fell within scope of the ERISA long-term disability plan’s pre-existing condition exclusion

Reliance Standard’s paper-reviewing consulting physician Carol Hulett, M.D. opined that Gustafson-Feis’s current hip injury was most likely the result of a gradual progression of the symptoms from her prior injury instead of being a new injury. The paper reviewer’s opinion failed to address how the prior condition caused the new injury, and it ignored the evidence that the new injury was likely caused by a congenital condition, not by the previous injury.

Gustafson-Feis filed suit to receive the benefits that Reliance Standard improperly denied under the ERISA LTD policy. Under Ninth Circuit law, courts apply federal common law to decide ERISA coverage disputes. Under federal common law, in order to bar the insured’s claim, Reliance Standard had the burden to show that the pre-existing condition exclusion applied. It had the burden to show that the new disability was “substantially caused or contributed to by the preexisting condition.” (Emphasis added.) Gustafson-Feis, 535 F.Supp.3d at 1085, citing Haddad v. SMG Long Term Disability Plan, 752 F.App’x 493, 494 (9th Cir. 2019). Because the exclusionary provision at issue was “narrow” – applying only if the disability results from, or is caused or contributed to by, a pre-existing condition – Reliance Standard needed to show that the pre-existing condition itself substantially caused or contributed to the disability. The court also noted that, under controlling Ninth Circuit law, the determination that a cause is “substantial” requires “some evidence of a significant magnitude of causation.” (Emphasis added.) Gustafson-Feis, at 1085, quoting Dowdy v. Metropolitan Life Ins. Co., 890 F.3d 802, 809 (9th Cir. 2018).

The court granted the insured’s motion for summary judgment and ordered Reliance Standard to pay LTD benefits. It found that Reliance Standard had not met its burden of proof. It explained that Reliance Standard’s mere contention that the new injury was “directly related” to the prior injury was insufficient to prove causation and that Reliance Standard’s paper reviewers did not identify, even generally, any degree of causation between the two injuries, much less the “significant magnitude of causation” required under applicable Ninth Circuit precedent. The court summarized its holding:

Dr. Hulett’s statement that Gustafson-Feis’s records are “most consistent with a gradual progression of symptoms” does not account for Gustafson-Feis’s trajectory—continued improvement and recovery through her return to work without restrictions in December of 2017, followed by severe impairment following the labral tear on her trip to China in May 2018. Specifically, Dr. Hulett does not explain how a labral tear would result from a gradual progression of the prior fractures or pain, does not assert that Gustafson-Feis would have been disabled by the lingering effects of her 2016 injuries had she not suffered the labral tear, and does not identify a degree of causation between the 2016 injuries and the 2018 labral tear. See id. at 809–10 (while wound healing was complicated by diabetes, the record did not show, “even generally,” how much of a role that complicating factor played in the plaintiff’s failure to recover).

. . .

Reliance has failed to engage with, let alone carry, its burden to establish that the [2016] accident was a substantial cause of Gustafson-Feis’s 2018 disability. There is certainly conflicting medical evidence in the record, and there is evidence from which a factfinder could find some degree of causation between the 2016 injuries and the 2018 disability. However, Reliance has the burden to prove substantial causation, and it has not made a sufficient showing to survive summary judgment.

Gustafson-Feis, at 1086.

It is important for individuals confronted by improper denials of disability coverage to seek counsel to review and assess the facts and policy terms and, if appropriate, sue to receive the benefits to which they are entitled. This is especially true with respect to insurer denials based on a policy’s pre-existing condition exclusion.