Long Term Disability Benefits Denied?
Denials of long term disability benefits under ERISA plans are fairly common. If you can’t work anymore and had to leave your job because of an illness or an injury, you probably turned to your long term disability policy that you have through your employer. These policies are supposed to protect you financially in the event of a disability if you can’t work anymore due to an injury, sickness or other impairment. They are often sold in the workplace as a benefit offered to employees, in much the same way that health insurance is offered. You, or your employer, pay into the plan and in theory, if you become disabled and can’t work anymore, you can use the policy so that you don’t have to worry about lost income. The problem is that many of these claims are routinely denied when they shouldn’t be.
Why did the insurance company deny my long term disability benefits if I can’t work?
Insurance companies exist to make a profit. That’s it. Every time that an insurance company has to pay out on a claim, it affects the company’s profit. Insurance companies and the people who work there are very incentivized to not pay out on claims and will come up with all kinds of excuses. Disability insurers are usually quick to send out denial letters, claiming that for some reason or another, the terms of the policy have not been met or that the person really can work, in the opinion of the insurance company. Many people are rightfully angry when they receive the denial letter, but also may think that there is nothing to be done. They may think, “Well, if the insurance company tells me I don’t meet the terms of my policy and don’t qualify, then that’s that”, and they give up. If this has happened to you, please understand that the insurance company does not try too hard (if at all) to approve your benefits. In fact, if they are looking into the details of your claim at all, it is to look for a reason to be able to deny you coverage. They want people who receive denial letters to just accept it and go away, so that the insurance company can save money. The sad truth is that many people, especially the disabled who are sick or in pain, do not have the energy to fight and just give up. They may try to file an appeal on their own without realizing the significance of the mistake that they are making in doing so without a lawyer. If the appeal is done incorrectly, it is usually the only chance that a claimant has and it cannot be fixed later on, not even in court.
How can the insurance company get away with not paying valid disability claims?
The truth is, the denials often go unchallenged. People who are unable to work may not have the energy to put up a fight or might not understand what it means to be able to appeal the decision. They might be under the very mistaken belief that the insurance company claims reps are on their side and begin to doubt even themselves as to whether or not they were entitled to collect to anything under the policy to begin with. Appealing sounds complicated, and it is. So many people just give up or take a letter from their doctor and send it in with a few words about why they don’t believe that they were treated fairly in the claims process. That is what insurance companies hope you will do- give up after reading your denial letter. For many disability providers, its all a numbers game. Are you going to let them win?
What protection do I have if I have been denied long term disability benefits under the policy I have through work?
With a few exceptions, if you have a group long term disability policy through work, your claim is governed by ERISA. ERISA is not an organization but rather, is an old, rather obscure and complicated Federal law. It dictates how employee benefits have to be handled and what happens when there is a dispute. ERISA gives you appeal rights and even the right to go to court, but in every other sense is highly stacked against you. Your best protection is to immediately speak to a lawyer who can handle an ERISA case. Because it is obscure, most lawyers do not handle these cases, even if they are employment lawyers or handle social security cases. We can help you.
ERISA stands for the Employee Retirement Income Security Act and it is a federal labor law that relates to the interests of participants of employee benefit plans, like a disability insurance policy. The law was signed by President Gerald Ford in 1974 to offer protection to working America and their pension funds. As the name would imply, it was originally intended to make sure that qualifying participants receive their pension benefits but then many other pieces were added to the law, including provisions dealing with how group long term disability policies have to be handled. You see, even the government does not trust the insurance companies to do right by their insureds. Some measure of protection may have been intended at the beginning, and while ERISA is supposed to hold disability insurance companies to a certain standard of accountability, the law unfortunately still favors the insurance companies. Nonetheless, it does give you the right to appeal your case and if you lose the appeal, you can take your case to federal court and sue. These cases are highly complex and easily messed up in the appeal process by individuals who try to navigate this themselves.
Why are the laws so unfair to claimants in long term disability cases governed by ERISA?
Here are the ways that insurance policies governed by ERISA turn out to be unfair or disadvantageous to the disabled party:
- There is typically only one shot at the appeal. Make a mistake and you are stuck with it.
- Very short and strict deadlines. In most cases, you will have only 180 days to submit your full appeal. This is 180 days from the time that you received your denial letter, and not 180 days from the date that your benefits actually ended- in case you were receiving claim benefits before. 180 days and that’s it. Turn it in late and all of your rights are gone.
- Your appeal is being appealed not to a court, not to a judge and not to a jury, or even to an impartial administrative panel, but it is being sent right back to your own insurance company. That’s right. The same insurance company that denied your benefits to begin with.
- If you lose the appeal, you can file a case in court, but you can’t pick and choose which court or which set of laws will apply. Any state court laws that might protect people in regular contract cases aren’t going to do you any good because if ERISA applies, that is what you are stuck with and off to federal court you go.
- You are not allowed to file your case in court until you have first filed an appeal. More hoops for you to jump through, potentially adding to the time it will take to resolve your case and get your much needed benefits.
- If you file your case in federal court, there is no discovery or trial. Your lawyer doesn’t grill the insurance company’s doctor about how much they get paid by the insurance company every year. There is no putting you on the stand to tell your story. The right to a trial by jury exists in criminal cases, not here.
- If you file a lawsuit, all of the evidence will be based on the appeal that was filed. This is what the judge will see and there is no going back to fix it if it was done in a shoddy manner or by a layperson.
- There are no punitive damages. Punitive damages exist is some other areas of law to punish a wrongdoer. Even if the insurance company behaved in a completely outrageous manner (which is about the only way that they can lose), the court cannot punish them by giving you a higher award. Nor do they have to pay your legal fees or anything like pain and suffering for all of the aggravation that they caused you. All you are recovering is the right to your back benefits and reinstatement of your benefits, which is what they were supposed to give you to begin with. Notice that there is no real risk to the insurance company if they deny you when they shouldn’t have.
- When you win, there is no guarantee as to how long your future benefits have to last. The insurance companies can come back again in the future to question your benefits, resulting in possibly more appeals down the road (we will stick with you for the long haul and deal with the insurance company for you and do everything possible to keep you on claim if you are still disabled and cannot work). In other words, winning your case does not shield you from future inquiries by the insurance company.
- If your case goes to court and a lawsuit is filed (after your appeal is denied), even if the judge agrees with you and would have made a different decision than the one that the insurance company did, if there is any basis to say that the insurance company may have acted reasonably when they made their decision, you can lose the case. This is an extremely skewed standard!
- The cases are also lot of work, even though this does not fall into the category of ‘unfair’. The amount of work should not a big deal to most lawyers who enjoy analyzing a lot of data and writing, but for people who want to try to do a good job on their own, it is overwhelming and also highly regulated with many complexities.
Even having just learned why these long term disability appeal cases are so unfair and so hard, do not give up! Let us take the burden from you and start by at least reviewing your denial letter and helping you come up with a strategy. There is no cost to review your letter.
How do I know if my long term disability benefits were actually wrongfully denied?
Not everyone who has been denied their benefits will have a winning case, which means that sometimes, the insurance company was correct and an individual does not qualify for long term disability benefits. But if you are here, you probably know in your heart that you have a valid claim, truly cannot work, and have a doctor that will back you up. The policy that you have is actually a legal contract and it must be reviewed very carefully. Does the insurance company’s reason for denial make sense under the legal language of the policy? It must be reviewed along with the facts of your own unique story. The relevant facts often will live within your medical records and what your doctor has to say becomes vitally important. This evaluation of the facts compared against the policy should be done by your own lawyer and not be trusted for correct handling by the insurance company whose interests are against yours.
If it looks like the insurance company was wrong, an appeal should be filed and this should be done by your lawyer, not by you because there is too much at stake in the appeal for long term disability benefits. Don’t count on your doctor to do this for you. Doctors are not lawyers and should not be writing legal appeals because it is just not what they are trained for. Most lawyers don’t even try to handle ERISA appeals. There are also very strict time frames associated with your legal rights. If you have been denied long term disability benefits through the policy that you have from work, do not wait because the clock is already ticking. Give us a call at 630 250-8813 to find out how we can help you.
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