ERISA Archives - Page 10 of 54 - McKennon Law Group

How to Speed Up Your Application for Long-Term Disability and Social Security Disability Benefits: The Compassionate Allowances Initiative

Compassionate Allowances Can Help Speed Up Social Security Disability Payments

Becoming disabled due to an injury or medical condition can be devastating. The thought of facing the future can be daunting, especially thinking about how you might manage financially. If you are unable to work, you likely have concerns about how you can cover your expenses.

If you are unable to work due to a disability, you will likely look to long-term disability insurance benefits or Social Security Disability Income (SSDI) benefits to help you survive financially. Disability benefits can be a vital lifeline for those who are unable to work.

However, getting SSDI or long-term disability benefits can be an extremely slow process. It can take several months or even years to get your claim for benefits approved. Many are simply not able to afford to wait so long to begin receiving benefits. .

You may be surprised to learn that once you submit a long-term disability claim with a private insurance company, such as through coverage you obtained as part of a group plan offered by your employer, it can take much longer for the claim to be approved and for you to begin receiving disability benefits than being approved for and receiving SSDI benefits. And, if you are able to get your SSDI benefits approved prior to your long-term disability benefits, a favorable decision can assist you in recovering long-term disability benefits. This is because under the law, insurance companies may be required to consider a favorable SSDI benefit award and may be required to give significant weight to such an award when making their own decisions.

The Social Security Administration understands how difficult it can be for people to wait so long for benefits and has therefore implemented Compassionate Allowances to help reduce the wait time for people who meet certain conditions. However, when it comes to private insurance companies, you may be at the mercy of the insurer’s timeline for reviewing your claim.

Find out more about Compassionate Allowances below and learn how the McKennon Law Group PC can help fight insurance companies for long-term disability benefits due to you.

Why Does it Take So Long to Get Approved for Disability Benefits?

Before the Social Security Administration will approve your claim for SSDI benefits, you must qualify for the program. During this process, the Social Security Administration looks at medical records and other documents to understand whether you are disabled from working and to what extent you maybe able to work.

To apply for SSDI benefits, you must complete lengthy paperwork related to your disabling condition and your daily life. You may also have to provide copies of medical records demonstrating that you have a disabling condition. The Social Security Administration may also request records from your medical providers, including hospitals, doctors’ offices, and physical therapy clinics.

This can be a slow process, especially given that the Social Security Administration is a large government agency. How quickly you provide the relevant information and documentation will impact how long it takes for the Social Security Administration to approve or deny your claim.

If the Social Security Administration denies your claim for SSDI benefits, you have options for appealing the decision. However, the appeals process itself can take several months or years, which will delay you receiving SSDI benefits by even longer.

Long-term disability claims with private insurance companies also may take a long time to be decided. The insurance company will need to obtain and review your medical records. If your claim is denied, the insurance company will likely have a process by which you can appeal the denial, which also can take a substantial amount of time. If your disability claim is governed by a federal law called ERISA, then the insurer is required to allow you to appeal any long-term disability claim denial.

The Relationship Between Social Security Disability Income Benefits and Disability Benefits From Private Insurers

There is a relationship between SSDI benefits and long-term disability benefits paid by private insurance companies. Your private disability policy obtained through your employer will almost certainly contain provisions allowing the insurer to “offset” income you receive from other sources of income against your disability benefits. The most common offset is one for SSDI benefits. The concept is that you may be entitled to receive a given monthly benefit amount, but you should not be able to earn more being disabled than you were when you were working.

Because of these provisions allowing insurers to offset other income against your disability benefits, disability policies commonly contain provisions requiring the covered person to seek SSDI benefits. These provisions often require that you apply for SSDI benefits, and sometimes require you to exhaust any available appeals. Many insurers will pay for legal counsel to handle your SSDI claim for you.

More importantly for you, a favorable determination on your SSDI claim will likely make it easier for you to qualify for long-term disability benefits with your employer or under your individual disability policy. Therefore, it may be in your interest to consider making claims for SSDI benefits and long-term disability simultaneously. At the very least, this can allow you to be more efficient with obtaining medical records and completing documents.

Why the Social Security Administration Has Compassionate Allowances

The Social Security Administration recognizes that some conditions lead to a disability 100% of the time. Therefore, persons who are diagnosed with such conditions do not need to prove their disability. They only have to demonstrate that they have the diagnosis.

Because of this, the Social Security Administration instituted Compassionate Allowances. This is a list of conditions that support the automatic approval of SSDI benefits. This saves time by avoidingr the lengthy claim process that involves a detailed review of your medical records.

Having a condition on the Compassionate Allowance list does not necessarily mean that you will not be required to go through a claim process with the Social Security Administration . You will still have to provide medical records or the Social Security Administration may still request them from your providers. Your claim and case will still go through a review process.

Some of the Conditions on the Compassionate Allowance List

The list of Compassionate Allowance conditions is quite long. It includes a variety of terminal illnesses, cancers, autoimmune disorders, mental health disorders, and musculoskeletal disorders.

Some of the Compassionate Allowance conditions are:

Acute leukemia
Breast cancer
Child lymphoma
Fatal familial insomnia
Lewy body dementia
Liver cancer
Perry syndrome
Seckel syndrome
Skin malignant melanoma with metastasis
Small cell cancer
Thyroid cancer

The best way to understand if your condition is on the list is to check for yourself. The Social Security Administration updates the list from time to time, so do not assume a condition is not on it simply because it was not on the list in the past.

It is also important to note that if your condition is not on the list, that does not mean that you will not be approved for disability benefits. It simply means that you will not get automatic and immediate distribution of benefits based on a Compassionate Allowance condition.

There is no such Compassionate Allowance program when you are dealing with a long-term disability claim involving a group disability policy from your employer or under an individual disability policy you obtained privately.

Get Help With Your Long-Term Disability Claim

Applying for long-term disability and SSDI benefits is a complex process. It is full of potential obstacles that can delay or hinder the process. A mistake on your application or a misunderstanding over your records can lead to an inappropriate denial of benefits. If you are struggling with these processes, feel you have been unfairly denied benefits, or you seem to be waiting forever for anything to happen, consider getting help.

Reach out to a reputable attorney for disability insurance in San Diego that is highly experienced with long-term disability claims. Call the McKennon Law Group PC at 800-682-4137 to make an appointment with our legal team. We will help you understand what your options are and how we can help you fight insurance companies hat are unfairly denying your disability insurance benefits.

Sixth Circuit Appeals Court Finds Claimant May Bring Separate ERISA Claims Where Those Claims Are Separate and Distinct From Each Other and the Injury Alleged in One Claim Cannot Be Remedied Through Another

The purpose of insurance companies is to generate profits, which they do by bringing in more revenue through premiums than they pay out in benefits. Naturally, then, they are motivated to avoid paying out benefits. Unsurprisingly, they will go to great lengths to find a reason to deny a claim for benefits. Even if the insurer or the claimant’s employer makes a mistake in administering the insurance policy or the claim, the insurer will likely take advantage of a situation that allows it to deny a claim, regardless of the impact on the claimant. For example, an employer may mistakenly fail to notify its insurer of an employee’s resignation or termination, so the insurer will not make any changes to the employee’s insurance enrollment. The employee may continue paying premiums thinking that he is still covered by the policy. When the employer catches its mistake, it retroactively terminates the policy. Then the insured suffers an injury and the beneficiary makes a claim, which the insurer predictably denies. Because the insured did not get notice that the coverage was terminated, he never had the opportunity to secure coverage from a different insurer.

In situations like this, the beneficiary can bring an ERISA claim against the insurer to recover benefits under the policy and another ERISA claim against both the employer and the insurer for breach of fiduciary duties. In response to a motion to dismiss such claims, the Sixth Circuit Court of Appeals recently found that the beneficiary’s claim against the employer should not be dismissed in Bailey v. United of Omaha Life Ins. Co., 2023 WL 2599979 (S.D. Ohio Mar. 22, 2023).

In Bailey, Adam Bailey was an employee of Hirschvogel Inc. from September 16, 2016 to September 24, 2019. During his employment, he obtained two life insurance policies (the “Policies”) taken out as part of an employee welfare benefit plan established by Hirschvogel under the provisions of ERISA. The plaintiff was Bailey’s son and the beneficiary of the life insurance policies at issue. His father terminated his employment, but a glitch in Hirschvogel’s system caused the company to fail to notify the insurer, United of Omaha, of several employees’ termination of employment, including his. The company caught the mistake and retroactively terminated his policies as of the time his employment ended, then he died in a car accident. Because he had been paying the premiums on the policies and had not been notified of the termination of his coverage under the policy, plaintiff filed a lawsuit asserting ERISA claims against Hirschvogel and the insurer for breach of fiduciary duties under Section 1132(a)(3) of ERISA (which acts as a catch-all provision to cover claims not covered in other ERISA provisions), and against the insurer to recover benefits due under the policy. Hirschvogel moved to dismiss the claim against it. The court denied the Hirschvogel’s motion and found that the plaintiff’s claim against Hirschvogel was adequate because the claim alleged an injury that was separate and distinct from the injury alleged in the claim for recovery of benefits and that could not be remedied through a claim brought under any other ERISA provision.

Regardless of the reason for Hirschvogel’s failure to notify United of Omaha of the termination of employment, Hirschvogel was bound as a fiduciary to take the necessary steps to ensure that such mistakes do not happen. Whether the plaintiff in Bailey will find success on the merits remains to be seen, but his claim survived the motion to dismiss by Hirschvogel under ERISA’s catch-all provision because it was separate and distinct from his claim for recovery of benefits and because his injury cannot be remedied through any other provision.

Bailey serves as an example to be diligent and understand the various provisions of ERISA. However, just because your particular claim is not covered by a specific policy/plan provision, that does not mean that you are not able to pursue that claim. McKennon Law Group PC has vast experience with ERISA claims and can assist ERISA plan participants and their beneficiaries with pursuing their employment benefits. If you would like to know whether you are to bring an ERISA claim against your insurer or employer, look to McKennon Law Group PC.

When Do You Have a Right to Your Retirement Benefits Under ERISA?

When Are You Fully Vested in Your ERISA Retirement Benefits?

You work hard for decades to save for the future, including retirement. You may work to contribute to an employer-sponsored retirement plan or to ensure you have a solid pension before retirement age. The last thing you want or expect is to be denied the benefits you worked so hard to earn. Yet this happens all too often. Employers and their retirement plan administrators will deny your claim for benefits for any number of reasons, including both legitimate and improper reasons.

McKennon Law Group PC can help you with your ERISA pension claim. We will fight to recover the ERISA benefits to which you are legally entitled. The knowledgeable and experienced attorneys at McKennon Law Group PC know how to aggressively seek recovery of your retirement benefits, as well as life insurance, health insurance and disability insurance benefits, so that they are paid. We stand up for you against insurance companies that are denying your insurance claims and against ERISA plan administrators who deny your retirement benefits.

Unfortunately, it is not always apparent to you when your situation involves issues that a lawyer can help with. Learn more about your rights under ERISA below so you can recognize when it is time to reach out to McKennon Law Group PC.

What Is ERISA?

ERISA is the Employee Retirement Income Security Act of 1974, the federal statute that provides standards for plans and employers that provide employee benefits such as pension and retirement plan benefits as well as disability, life, health and accidental death insurance benefits. ERISA does not require employers to provide these plans, but any employer that does provide such a plan must follow the minimum requirements as stated in ERISA.

What Does Vested Retirement Benefits Mean?

To say that you are fully vested in retirement benefits means that you are entitled to those benefits and that they cannot be taken away from you. If you are partially vested, you are entitled to a portion of the benefits that are vested. Benefits typically vest over time while working for your employer.

ERISA and ERISA retirement plans control how long and under what circumstances retirement plan benefits fully vest for participating employees.

Vesting for ERISA Benefits

An important ERISA rule is that you are immediately fully vested in your contributions to a retirement plan. Your employer may not withhold pay to put it into your retirement plan only to then keep you from accessing that money.

However, specific rules and ERISA plan terms dictate how you can access your contributions in each type of retirement plan. It is not as simple as withdrawing money like you do from your bank account. Because most pre-tax contributions are not taxed, you will likely owe taxes on any money you withdraw from the plan. The IRS may also impose withdrawal penalties if you take out money before you reach retirement age.

You may be able to borrow from your retirement savings account in some cases. Check with your plan provider or employer’s benefits office to find out what types of loans they allow. For example, some plans allow loans for buying a home or funding college expenses, which you may repay via an installment plan, with interest paid to your retirement account.

Your employer also may contribute to your retirement plan. For instance, employers that offer 401(k) plans may match contributions up to a limit. You might contribute 5 percent of your salary to the plan, and your employer contributes 3 percent.

It is important to understand that when your company provides retirement benefits, you are not necessarily immediately vested in those benefits, and you likely will not have an immediate right to them.

Depending on the plan and how your employer funds and provides benefits, it may take years to become fully vested. However, ERISA provides limits on how many years vesting can take, which keep employers or plans from making it impossible to become fully vested. ERISA also requires that you start vesting within a certain time, which varies depending on the plan schedule. For example, you may be 20 percent vested after two years of service, then your vesting increases gradually over a six-year period until you are fully vested. If you quit the job when you are 60 percent vested, you will be entitled to all of the benefits from your own contributions and 60 percent of the benefits from your employer’s contributions.

What To Do if Your ERISA Benefits Claim is Denied

It is illegal for your employer or plan to withhold ERISA benefits to which you are entitled. If you believe you are partially or fully vested in benefits and your employer or retirement plan administrator is not allowing you to access them, first contact your plan administrator. Sometimes, these issues are caused by administrative errors and may be easily resolved through simple communication. However, if you have communicated with the plan administrator and still are being denied access to your benefits, it is time to reach out to the team of knowledgeable attorneys at McKennon Law Group PC at 800-682-4137. The experienced lawyers at McKennon Law Group PC will fight for you and recover your ERISA pension benefits.

How to Handle Denied Accidental Death And Dismemberment Claims

Handling Your Denied AD&D Claim

If you submitted an accidental death and dismemberment (AD&D) claim for benefits and your insurance company has denied it, you may feel at a loss with what to do next. There is a good chance you will still be able to recover your AD&D benefits. However, there are also things you may think will help your claim that may in fact harm your claim and reduce your ability to recover AD&D benefits. Below are some things to do and to avoid doing to ensure the greatest likelihood of being awarded your AD&D benefits.

Do:

• Consult with an experienced AD&D/accidental death insurance attorney to understand the claims process, the accidental death insurance claim denial and your rights and obligations
• Understand that it is in the insurance company’s best interest to deny claims as opposed to paying them out. Do not be surprised if the insurance company finds any basis it can to deny your claim, no matter how unreasonable that basis may seem
• Gather any and all AD&D insurance policy documentation
• Gather any medical, hospital, or autopsy records that pertain to your case, including a death certificate, police report, or incident/accident reports
• Consider hiring your own experts as you may need an expert opinion (e.g., a pathologist to perform an autopsy or other examination separate from the insurance company; an accident reconstruction expert to examine the nature and cause of the accident
• Contact potential witnesses

Avoid:
• Assuming that just because the death certificate lists the reason for death as accidental that the insurance company will approve your AD&D claim
• Talking to or providing any information to your insurance company without first speaking to an attorney
• Attempting to fight an insurer’s accidental death insurance denial on your own. Instead, talk to an experienced AD&D insurance lawyer who can guide you.

Common Reasons Accidental Death And Dismemberment Claims Are Denied

Insurance companies often deny AD&D claims for many reasons, but the most common two reasons are that the death or injury was not caused by an accident, or that coverage for the death or injury is excluded in the policy. AD&D claims are also commonly denied for reasons like failing to pay premiums, or because the death occurred too long after the accident, and it is no longer covered under your AD&D policy.

When Death Or Dismemberment Was Not Caused By An Accident

Because AD&D policies are only designed for “accidental” death and injury, a death or dismemberment caused by anything other than an accident will likely not be covered. However, the exact cause of death is not always obvious and there often exists a distinction between a “contributing” cause and a cause that “substantially” contributes to the death or dismemberment. This distinction is critical in most cases and understanding how and when to apply this distinction can only be made by an experienced accidental death insurance claim attorney. Insurance companies will try to avoid these distinctions when they deny accidental death insurance claims.

When Coverage For Death Or Dismemberment is Excluded By The Policy

Your AD&D policy has a list of exclusions to coverage, which identifies situations under which the policy does not cover accidental death or dismemberment. Some typical exclusions are death caused by illegal drug overdose taken without a prescription, death or injury caused by driving under the influence of drugs or alcohol, and suicide or a medical condition contributing to the accidental death. Policy exclusions vary between different insurers and policies. To avoid being caught off guard by a policy exclusion, it is best that you read and fully understand what your policy covers and what it excludes. But even reading the policy exclusions may not be indicative of the outcome as legal decisions and the laws in several states may alter the interpretation of the policy exclusion. Only an experienced AD&D attorney will be able to guide you on the legal interpretations.

How An Experienced AD&D Insurance Lawyer Can Help You If Your Accidental Death And Dismemberment Claim Is Denied

We have discussed above several circumstances in which you will want to consider hiring an experienced accidental death insurance claim attorney. If your claim was denied, the first thing to understand is that a claim denial is not the end of the line. Under most circumstances, you have the right to appeal the insurance company’s denial of your claim. If you did not consult an attorney before filing an initial claim, now is the time to consider hiring a qualified AD&D claim attorney. Be aware that you will have a deadline by which the insurance company must receive your appeal, which may vary from state to state or which may be determined by a federal law called ERISA. If your AD&D claim was denied and you are interested in appealing the denial, the best plan of action is to start by contacting an experienced AD&D insurance lawyer who will be able to help you understand why your initial claim was denied and ensure you have the best chance of receiving the benefits to which you are entitled under your AD&D policy.

The highly experienced AD&D insurance attorneys at McKennon Law Group PC provide free consultations so you can get your AD&D insurance questions answered. And if you choose to pursue legal action, McKennon Law Group PC has a team of experienced AD&D insurance attorneys ready to assist you in recovering the benefits you are owed under your AD&D policy.

Do You Need to File a Long-Term Care Insurance Claim?

3 Signs It Might Be Time to Consider Filing a Long-Term Care Insurance Claim

There are more than 28,000 licensed assisted living communities in the nation in addition to many more nursing homes and other long-term care facilities. These various care providers offer a safe space for older adults who need long-term care due to physical or mental concerns.

How do you know when it is time to file a claim with your long-term care insurer? Every situation, individual, and family is unique. It is important to consider your own needs and goals, consult with your primary care physician and other providers, and talk to your loved ones about how best to approach care in the future. And, strongly consider consulting a long-term care insurance claim attorney to answer questions and assist with filing such a claim. The following are some common signs that you or a loved one might need to file a long-term care insurance claim.

1. Activities of Daily Living Have Become Too Challenging

Almost all long-term care insurance policies cover you if you are unable to perform certain categories of activities of daily living, or ADLs. They include tasks such as eating, drinking, dressing, toileting, bathing, or walking or other mobility. Many long-term care policies also provide benefits if you are suffering from significant cognitive impairment that prevents you or a loved one from performing ADLs.

If you or someone you know is struggling with performing basic ADLs as identified above, it can be an indication you or they need support and thus should file a claim for long-term care insurance benefits. The care needed might come in the form of long-term care, such as moving into an independent or assisted living community. Or, it might include getting some in-home help. Having loved ones help with laundry, cleaning, preparing meals, using the toilet, bathing, getting dressed are all ways to address challenges with ADLs.

Challenges with these basic ADLs are a sign that long-term care is necessary and that you should apply for long-term care benefits. If someone is struggling to feed themselves, get dressed, use the toilet, bathe themselves or move around their home safely, they may need more supervision and assistance than family caregivers can provide, and it may be necessary to file a claim for long-term care benefits.

2. Experiencing Serious Memory Problems

Signs of memory issues or progressing memory diseases such as dementia can be a reason to consider long-term care insurance benefits. In a memory care community or nursing home, you can get the care and support you need to continue with an active and safe lifestyle.

In many cases, these communities and care providers offer activities and other services that help to sustain the cognitive function you need to stave off memory decline. Serious memory problems will often cause inability to perform basic ADLs.

3. Worsening Chronic Health Conditions

Serious chronic health conditions can require ongoing diet, medication, and exercise support. If you or someone you know are struggling to manage your chronic conditions at home or they are worsening to the point that you are at a greater risk and unable to perform ADLs, you should consider filing a claim for long-term care insurance benefits.

We Fight for Your Benefits

Are you interested in filing a claim for long-term care benefits with your insurer? Or is your long-term care insurer refusing coverage you think should be available? Reach out to the McKennon Law Group, PC. We fight insurance companies to ensure you get the long-term care insurance benefits you are entitled to.

Accidental Death And Dismemberment Claims

How Do I File An Accidental Death And Dismemberment Claim?

If you are insured by an Accidental Death and Dismemberment (AD&D) policy, your beneficiary will be entitled to benefits if an accident causes your death or dismemberment. Similarly, if you are the beneficiary of someone else’s AD&D policy, you may be entitled to benefits if an accident causes that person’s death or dismemberment. However, AD&D policies typically have stringent requirements and several exclusions to coverage. An insurance company will deny benefits whenever it is able to use a policy requirement or exclusion to do so. Therefore, it is important that you understand and properly follow the claims process.

When there has been a death or dismemberment caused by an accidental event, the first thing to do is gather all the relevant documentation, which will include:

AD&D policy
AD&D claim documents
Copies of medical records
Records of any hospital stays or surgery
Autopsy reports
Police/Accident reports
Death certificate.

The next step will be demonstrating that your claim is payable because it is covered by the policy. The death or dismemberment must be the result of some type of accidental event. Simply because a death certificate or autopsy report characterizes death as an “accident” does not make it an accident in the skeptical eyes of an insurer. If there is any other contributing cause of the loss, such as an illness, medical event or intoxication, you can expect the insurance company to deny your claim. For example, if the insured passed away at a hospital, you should provide evidence that the death was caused by an accident and not solely by an illness, like a subdural hematoma, which may have been caused by an accidental event, such as a car accident or fall. The more relevant evidence you provide, the more likely the insurance company will pay your claim.

What Can I Do If My Claim Is Denied?

If your claim for AD&D benefits is denied, you should immediately contact an experienced accidental death insurance/AD&D lawyer. Insurance companies deny claims for many different reasons, and they often deny claims that should be paid. If your claim is denied, you will likely be left wondering what your options are or what to do next. An experienced accidental death insurance/AD&D lawyer will be able to evaluate the merits of the case and advise you on your next steps, which may be an administrative appeal to the same insurer or a lawsuit. A qualified lawyer can recommend documents to obtain, can perform legal research, can hire needed experts, and can assemble the evidence necessary to convince the insurer or a court of law that the accidental death/AD&D claim is payable.

At McKennon Law Group PC, we have the experienced and knowledgeable attorneys to provide you with the representation you need. We offer free consultations to assess your accidental death insurance/AD&D matter. Contact McKennon Law Group PC today and speak to our highly qualified team of accidental death insurance/AD&D lawyers for all your AD&D insurance needs.