 Many people receive their disability insurance through their employer or some other group plan. In 1974, the United States Congress passed the Employee Retirement Income Security Act also known as ERISA. This is the law that pertains to disability insurance provided by groups and/or employers. ERISA laws effecting claims for disability insurance benefits are somewhat different than those for people who purchased their disability insurance on their own. Understanding these differences is necessary when asking an insurance company to make good on their obligations and promises. What follows are a few questions related to ERISA disability benefits and insurance. If you have an ERISA question not listed here, please give us a call or send us an email message. We will be happy to review your claim and discuss your options.
Frequently Asked Questions
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1. How does ERISA affect my claim for disability benefits?
The Employee Retirement Income Security Act of 1974 dictates how insurance companies administer and manage the policies they sell and the people they insure under group or employer sponsored insurance plans. This Federal statute also governs the rights and requirements of the plan's beneficiaries ... the people who receive the insurance benefits. If you or someone you care about receives disability or life insurance from an employer, then the ERISA law applies. As a claimant you may seek to have your disability benefits restored by filing a lawsuit. In most cases, you can only do this after you have followed the all of the ERISA required procedures. Most claimants are required to respond to all denial of benefits (you must file an appeal) and do so within the allotted time frame or risk losing the ability to file a lawsuit at some point in the future.
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2. Do I have to talk to the insurance company representative if they come to my home or office to interview me?
If you are represented by an attorney then your insurance company cannot directly communicate with you without your attorney being present; whether in person or on the telephone. Insurance companies like to talk to claimants alone before they hire a lawyer because they stand a better chance of being able to manipulate the situation to their benefit. If you or a loved one is disabled and having to deal with an insurance company, having an ERISA lawyer on your side is a really good idea.
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3. Do I have to go to the insurance company's independent medical examination or IME?
Many ERISA policies require you to submit to an independent medical examination also known as an IME. These examinations are not necessarily independent, considering the person conducting the exam is usually hired by the insurance company that should be paying your disability benefits. There is an inherent conflict of interest in the IME process. If the medical examiner find in your favor then the insurance company must pay your disability benefits. Insurance companies are in business to make money. They do this by collecting insurance premium revenue and by limiting the number of claims they pay out. If a medical examiner continually cost the insurance company money, they will no longer hire that person to conduct IMEs. To answer this question you need to look closely at your insurance policy. The answer will most likely be buried in the fine print. While your insurance company may have the right to require you to attend an examination, how and by whom the examination is conducted may limit the information they are able to gather. A qualified ERISA lawyer can help you.
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4. How can my insurance company deny my disability benefits claim for a "mental and nervous limitation provision" when that is not my disability?
Insurance companies know if they make a claim (even if it is not true), they can buy time to delay or deny your benefits while you prove the claim is inaccurate or untrue. It is not uncommon for insurance companies to deny disability benefits claiming a "mental and nervous limitation" provision in the claimants policy even when this condition is not related to the claimant's disability. Insurance providers will even resort to using medical sources such as the Diagnostic and Statistical Manual of Mental Disorders or DSM-IV to find rare (unrelated) conditions in order to make a claim for a "mental and nervous limitation provision." Do not let this happen to you or someone you care about.
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5. What happens now that my insurance company has denied my claim for disability benefits?
Once your claim for disability benefits has been denied, you will probably need to file an appeal and be required to "exhaust your administrative remedies" before you can file a lawsuit against your insurance company. When you file an appeal, you're asking your insurance carrier to review your claims, reconsider their decision and restore your disability benefits. While you may win one or more appeals, eventually the insurance company will most likely terminate your benefits. This is why we suggest you consider hiring an ERISA / disability attorney to act on your behalf and too look out for your best interest.
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6. How can my insurance company deny my disability benefits claim even though I am not able to work?
Insurance companies can claim just about anything for any reason. The burden to prove otherwise --that their claims for disability benefits are valid, rest with the claimant. Insurance providers will often delay or deny a claim for disability benefits by stating the claimant has failed to meet the definition of "disability." This is done by changing the definition of disability from "your occupation" to "any occupation." This usually occurs after the insurance company reviews your medical information. Claims can also be denied for a variety of other reasons such as a pre-existing condition or other exclusions or limitations buried in the fine print of your policy. Just because you are not able to work does not prevent your insurance company from looking for any reason to delay or deny paying your disability income benefits.
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