ERISA

Introduction

When you went to work for your employer, you may have been offered different types of insurance benefits – such as health coverage, disability insurance (both short and long-term), retirement benefits, or long-term care benefits. The Employee Retirement Income Security Act, known as ERISA, was put into place to ensure that your employer follows through with that offer.  All private employees who have signed up for an offered plan are covered under the law.  While we can help you with denials of virtually any type of benefit, the most common requests we receive are for help appealing a denial of long-term or short-term disability claims by the employer’s insurance carrier.

When Do I File a Claim?

For disability claims covered under a benefit plan, you should ask either your employer or your employer’s insurance carrier for the written claims procedure.  This should give you a breakdown of each step you will need to take in order to apply for benefits under the company plan.  As the Department of Labor explains, deadlines in this area vary, so applying as soon as possible is strongly recommended:

“All plans have standards you must meet to qualify for benefits. Your pension plan will probably say that you must have worked a certain number of years and/or be a certain age before you can start receiving benefits. Some employee welfare benefit plans may require you to file a claim or notify the plan administrator immediately when you enter a hospital or see a doctor.”  DOL.gov.

You should receive a decision on your application for benefits within 90 days.  If you have not, then the insurance carrier has to tell you why.  If you are denied, the decision or the claims procedure should outline how to appeal the decision.

What Do I Do if I’m Denied?

If you are denied by either a denial letter or by the insurance company failing to give you a decision, then your plan may only give you 60 days to be appealed to the insurance carrier’s appeals system.  The denial letter should run down most of the reasons that your claim was denied.  The appeal review in many cases can take up to 120 days to render a decision.  If you are denied again, you only remaining option is an expensive trip to court.

When Should I Hire an Attorney?

My recommendation in this area is to hire an attorney as soon as you are considering filing for disability benefits.  The application process can vary in difficulty depending on which insurance carrier your company uses, but most follow the same general standards required by law.  These standards can be very confusing for both you and your doctor, and a failure to succeed on the first try could lead to 4 months – if not more – passing before you are paid.  Since you are disabled and unable to earn an income during this time, going for such a long period without any money coming in could be disastrous.  If you are financially able, then you may want to simply hire us to review your documents and inform you if we think you are qualified for disability benefits under your plan, then apply for disability yourself.  However, your initial appeal should undoubtedly be done with the help of an attorney.  Your only option after the initial appeal is a lengthy and costly court case which should be avoided if possible.

If you are considering applying for disability benefits through your employer’s plan or you believe that you were improperly denied benefits, contact us today.