ERISA Short-Term and Long-Term Disability Appeals

 Do you have disability insurance, short-term or long-term, provided by your employer?

Have you become unable to work because of illness or injury?

Has the insurance company wrongly denied or terminated your benefits?

 

Unfortunately, the insurance companies that contract with employers to provide disability coverage all too often deny valid disability claims, asserting that the recipient does not meet their definition of disability. The insurance company, not your employer, decides whether you meet its particular legal definition of disability, and that definition can change depending how long you have been disabled. It is not enough for your doctor to say that you are unable to work. If your benefits have been denied or terminated, you will need to assemble an extensive administrative file with documentation from multiple sources and submit your appeal to the insurance company on a strict timeline. If the insurance company denies the appeal, the decision can be further appealed by filing a lawsuit in federal court under ERISA.  

What is ERISA?

ERISA is a federal law, the Employee Retirement Income Security Act of 1974. This law governs most employer-sponsored benefits, including pensions, health and disability insurance. ERISA provides precise rules and procedures that you must follow to appeal your claim. ERISA preempts state laws. This preemption generally favors employers and insurers, but the law does provide some protections, as well as procedures that must be followed.

In general terms, the first step in challenging the insurance company's decision is to file an internal appeal with the insurance company. Some insurers provide two levels of internal review. If the internal appeal is unsuccessful, the next step is to file suit against the insurance company in federal court, based on the information in the administrative file. In most cases you must exhaust the internal review process before filing a lawsuit.

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