How Do I Apply For Long-Term Disability benefits Under ERISA?
HandelontheLaw.com Staff Writer
“ERISA” is the Employee Retirement Income Security Act, a Federal law governing several healthcare aspects, including most long-term group disability plans provided by employers. Distinct from individual insurance plans, an ERISA plan has federally-mandated guidelines for obtaining long-term disability benefits. Claims for these benefits should be as strong as possible at the outset, closely following federal guidelines and backed by as much supporting evidence as possible; initial denials are tough to overturn, even with a federal suit allowed by ERISA.
How, then, can you successfully apply for long-term disability benefits under your employer’s ERISA plan?
First, before you stop working (if at all possible), quickly consult/retain a lawyer who specializes in ERISA long-term disability claims. The process for obtaining benefits can be complicated and it requires your compliance with important deadlines and rules of evidence. The process and the evidence you gather can make or break your claim; consequently, this is not the time for you to: quit before you are officially “disabled”; rely on your own skills; rely on the skills of someone else who works for your employer; rely on the benevolence of insurance company’s lawyers; rely on the skills of any other lawyer who lacks experience with ERISA claims. Find and hire the experienced ERISA lawyer. He/she will begin gathering evidence and help you choose your “Last Day Worked,” which is important for your claim process.
Second, obtain a copy of your insurance policy from your employer. With or without your lawyer (but preferably with your lawyer), you can obtain a copy of your Summary Plan Description by your written request to the plan administrator. This will tell you what the insurance plan does and does not cover.
Third, you must focus on convincing the insurance company that you are entitled to long-term disability benefits. Your lawyer will know the type and amount of evidence that can convince an insurance company that you fit the required legal definitions; consequently, you should rely heavily on his/her advice rather than the opinions of your employer or of anyone working for your employer or of anyone working for the insurance company.
Fourth, with your lawyer’s assistance, determine your date of disability because that date triggers key dates for your claim process and benefits. You and your lawyer will be able to determine this date by reviewing your policy and the facts of your case.
Fifth, with your lawyer’s assistance, you will receive insurance forms that must be completed and timely submitted by you, your doctor and your lawyer. Complete these forms and obtain any additional doctor’s reports about how your disability stops you from “performing the substantial and material duties” of your job. Again, your lawyer will know the insurance forms and additional evidence that must be provided for a successful initial claim.
Sixth, with your lawyer’s assistance, obtain copies of all records – medical and otherwise – that support your claim. An experienced lawyer will know and do this as a matter of course but will need your assistance to do so.
Seventh, do what your lawyer and your doctor tell you to do and don’t do what they tell you not to do. You have probably seen television shows or movies in which an insurance company watches a person to see whether he/she is really disabled; that’s no joke. The insurance company will keep tabs on your activities and might even have you log them. Your lawyer and doctor are well aware of that and will tell you to avoid certain activities. Follow their advice.
Eighth, your lawyer will guide you through the complicated claims process and any necessary appeals process if your initial claim is denied.
DO’S AND DON’TS
DON’T be intimidated by the process or the people.
DO quickly consult/retain a lawyer who specializes in ERISA long-term disability claims before you stop working (if at all possible).
DO obtain a copy of your insurance policy/Summary Plan Description from your employer.
DO focus on convincing the insurance company that you are entitled to long-term disability benefits.
DO determine your date of disability.
DO determine your last day worked.
DO ensure that all insurance forms and additional required reports are completed and submitted by you, your doctor and your lawyer.
DO obtain copies of all records – medical and otherwise – that support your claim.
DO what your lawyer and your doctor tell you.
DON’T engage in activities that your lawyer and doctor tell you to avoid.
DO rely heavily on your lawyer’s guidance through this complicated process, which might include an appeal.
DO familiarize yourself with the strict ERISA deadlines to ensure that your claim is meeting them.
By Kathy Catanzarite
[Note from HandelontheLaw.com: This article is to be used as an educational guide only and should not be interpreted as a legal consultation. Readers of this article are advised to seek an attorney if a legal consultation is needed. Laws may vary by state and are subject to change, thus the accuracy of this information cannot be guaranteed. Readers act on this information solely at their own risk. Neither HandelontheLaw.com, or any of its affiliates, shall have any liability stemming from this article.]
Note from HandelontheLaw.com: This article is to be used as an educational guide only and should not be interpreted as a legal consultation. Readers of this article are advised to seek an attorney if a legal consultation is needed. Laws may vary by state and are subject to change, thus the accuracy of this information can not be guaranteed. Readers act on this information solely at their own risk. Neither the author, handelonthelaw.com, or any of its affiliates shall have any liability stemming from this article.