The long-term disability coverage that your employer has been providing may not be there when you need it. That is why, even before you file your disability claim, you should seek the advice of a California ERISA disability claims attorney.

The Employee Retirement Income Security Act – also known as ERISA – was enacted by Congress in 1974 to make sure that the insurance benefits provided by private employers will be there when employees need those benefits.

ERISA sets minimum legal requirements for the group insurance plans provided through many employers in the private sector. However, long-term disability claims under ERISA are routinely denied by insurance companies. If you need disability benefits that have been denied, you may also need seek the services of a top-rated legal expert for disability insurance cases in San Diego.

What Does a Long-Term Disability Policy Cover?

Long-term disability insurance typically provide benefits if you are unable to perform the important duties of your own occupation due to an injury or sickness. Most disability policies cover a variety of serious illnesses and medical conditions, whether they are classified as physical medical conditions or mental-nervous conditions. On-the-job injuries may be covered, but about 95 percent of the long-term disability claims filed under ERISA are not work-related.

Cancer, mental illness such as depression or anxiety conditions, chronic illnesses, neurological disorders, and certain degenerative diseases may also be covered by your ERISA disability policy.

What Does ERISA Require?

ERISA does not require private employers to provide employee benefit plans. The federal law simply establishes minimum standards for insurance plans that employers choose voluntarily to offer.

When an insurance company or an employer takes advantage of ERISA to reject a disability claim and unfairly deny disability benefits, a California ERISA claims lawyer may be able to appeal the denial of that claim and recover the benefits, or if that appeal is denied, file a lawsuit in federal court to recover these denied disability insurance benefits.

Why are disability claims under ERISA so frequently denied? Are there ways to avoid the most common reasons for denials? How can a denial be appealed, what are your rights if your claim is denied, and what steps will you have to take? These questions will be answered below.

Avoid These Mistakes If You File an ERISA Disability Benefits Claim

If you consult an ERISA claims attorney before you file your ERISA disability benefits claim, your attorney can assist you to avoid these common mistakes, and it is even possible that your claim may be approved:

1.  When a doctor determines that you are disabled, do not assume that you will qualify for disability benefits. Insurers frequently deny disability claims even those that are supported by one or more of the insured’s doctors. Have your doctors write up a comprehensive evaluation of your condition and your disability that discusses your medical conditions and how these conditions affect your ability to conduct everyday activities and your job duties.
2.  Provide a comprehensive statement from you and others that discuss in detail why you are disabled. The statement must include the following information: 1) a detailed description of the duties of your occupation as you performed them; 2) a detailed discussion of the history of your condition; 3) a detailed discussion of your symptoms; 4) an explanation for how those symptoms negatively impact your ability to return to work such that you cannot work; 5) how your disability also impacts your overall quality of life; and 6) a discussion of the things you could previously do but can no longer do.
3.  Adhere to your doctor’s recommendations and do not participate in any physical activities against those recommendations. Do not post anything about your claim online or give the insurer anything that could be used to justify the denial of your disability claim.
4.  The easiest mistake to avoid when you make a claim for ERISA benefits is not working with an ERISA claims lawyer from the start. You must have sound advice because ERISA is a complicated law with many exemptions, terms, conditions, and deadlines.

Will Your ERISA Disability Claim Be Denied?

An ERISA disability claim could be denied for almost any reason – if you make a mistake in the paperwork, for example, or if you miss something in your policy’s fine print. Here are the most common reasons offered by disability insurance providers for denying ERISA disability claims:

1.  inadequate medical documentation of a disability
2. a pre-existing condition
3. missing details, paperwork mistakes, and overlooked deadlines
4. policy exclusions
5. self-reported, undocumented symptoms or unauthorized or inappropriate treatment
6. evidence compiled through social media or private investigation contradicting your claim

When you’ve paid an insurance company premiums for years, and when a doctor has determined that you are disabled, receiving a letter from your insurance company that denies your disability claim can be devastating.

Too often, legitimate disability claims are denied because some insurance companies look for every possible technicality that will allow them to reject a claim. However, an experienced ERISA disability claims attorney may be able to help you if your claim is rejected.

What Are the Rules for ERISA Disability Claims?

Before 2018, you could sue an ERISA insurance provider for the denial of disability benefits only if you and your lawyer could prove the denial was “arbitrary and capricious.” But since 2018, ERISA insurers must provide a “reasoned explanation” when a disability claim is denied.

An insurance company must clearly explain why it disagrees when one or more doctors have concluded that you’re disabled. The company must also identify which of its procedures and policies authorize and support its denial of your claim.

One rule governing disability claims was not changed in 2018. You may not sue an ERISA disability insurance provider until one or more “administrative” appeals of the denial have been filed and considered by that insurance provider.

When Should You Speak to an ERISA Attorney?

When you file a long-term disability claim under ERISA, your best option is having the guidance and advice of a California ERISA claims attorney from the start – even before you begin to fill out the insurance company’s paperwork.

But if your disability claim under ERISA is denied, and if you are not already working with a lawyer, speak with a claims lawyer at once about filing an appeal. A claims lawyer can handle your appeal and ensure that you’ve complied with ERISA’s numerous guidelines.

Because ERISA is a federal law, U.S. District Courts hear ERISA-related lawsuits. If the insurance company rejects your administrative appeal, your attorney may recommend bringing a lawsuit in a U.S. District Court, where a District Judge will decide the case.

What Else Will You Need to Know?

You will need personalized guidance and advice if you apply for disability benefits under ERISA or if your claim is rejected. Your lawyer should have considerable experience representing disabled clients and appealing the denial of their ERISA disability claims.

ERISA does not apply to public-sector employees or to the employees of religious organizations. It also does not cover privately-purchased, individual insurance policies or any benefit or program that is not provided by a private-sector employer.

Most California attorneys who handle ERISA claims provide an initial legal consultation to prospective clients without any obligation or cost. That consultation is your chance to obtain personalized legal advice and to find out more about your rights and legal options.

If you’re disabled, and if you intend to claim disability benefits under ERISA, or if your claim has already been denied, there’s no reason to wait. Do what it takes to obtain the disability benefits you have paid for and need, and contact a California ERISA claims lawyer at once.