The laws that govern employer provided long-term disability appeals is a complex area of insurance law that becomes very confusing when filing for disability. The attorneys at Murray Law Office are well-trained in ERISA and can make the process less stressful and advocate effectively on your behalf.
When you are injured/ill/sick and unable to work, one would think that you should be able to rely on your long-term disability coverage through your employer. However, instead of focusing on your health and recovery, the claim process when filing a disability claim is a confusing, stressful, and complex ordeal that can add to your stress when undergoing a major life change. When filing your claim against the insurance company, you may potentially run into a number of issues that could limit the amount you receive and/or jeopardize your ability to recover ANY money from your insurance carrier.
While each case is unique, retaining a Long-Term Disability Attorney can be very helpful to succeeding with your claim when you are up against a large insurance company who has a team of specially trained adjusters, doctors, and attorneys fighting against you. If you become disabled, you should hire an attorney well-versed in ERISA because:
1. We will help you determine whether your policy is governed under ERISA or State Laws. There are two types of law that govern short and long-term disability policies: ERISA and State Law. ERISA (Employee Retirement Income Security Act) is a federal statute that governs short and long-term disability claims as well as employee benefit plans. ERISA can be extremely unfair to claimants as many policies contain a contractual provision which substantially increases what you are required to submit to demonstrate your eligibility to benefits. Further, these policies can be filled with a plethora of loopholes and exclusions where your insurance company is not legally required to pay you anything even if you are legitimately disabled. To make matters more confusing, while most employer provides policies are governed by ERISA, some can be exempt if your employer is a religious organization, governmental entity or agency.
If not governed under ERISA, your long-term disability policy is most likely governed under State Law, which tends to be much fairer and is not fraught with the number of loopholes and exclusions found in most ERISA policies. However, even if your policy is not governed by ERISA, your insurance company may still assert that it is governed by ERISA, sometimes using specific ERISA language. Because of this, we urge you to speak to a trained ERISA lawyer at Murray Law Office. We will help you determine whether your policy falls under ERISA law and what legal ramifications it will mean.
2. We will help you determine your legal remedies and how to strengthen your appeal. Clients bear the burden of proof, and as a result, an insurance company has no obligation to make your case for you. While the insurance company may seem helpful and will sometimes try to gather information for you when you ask to appeal, they will not tell you how to strengthen your case nor can you blame them if, in retrospect, you could have submitted proper information to support your claim but they failed to gather it for you.
When you are denied, it is your responsibility to prove why the insurance company’s decision was wrong AND (in most cases) why their decision was unreasonable and not supported by even a scintilla of evidence. Determining your legal remedies and arguments requires a complex analysis of your medical records, policy, the claim file, and a myriad of cases that have been previously decided across the country where prior courts have issued rulings interpreting the reasons the insurer relied on when terminated or denied your claim as applied to the specific facts of your case. The attorneys at Murray Law Office will analyze your case so that we prepare appeals properly and aggressively advocate on your behalf.
3. We will make sure to introduce all evidence in time. ERISA guidelines have strict deadlines and guidelines that employees need to follow, at the risk of losing eligibility for benefits. If your long-term disability claim under ERISA is denied, you must navigate through a complex appeal process. Further, ERISA has an Exhaustion Requirement where you can waive arguments if you fail to raise them in your appeal or submit the appeal on a timely basis. To make matters even more unfair, once you have submitted your appeal, you are not allowed to introduce any new information once the insurance company has made a final decision if they deny you again when you seek the court’s help following a final decision.
Unfortunately, too often clients have often come to us after they decided to do their own legal work and their appeal has been denied, only to find out that they have exhausted their remedies, failed to submit what is required of them pursuant to the case law, and severely limited or prohibited the money they should have received if they decided to seek competent representation before appealing. Murray Law Office will ensure that all deadlines are met and all avenues of recovery have been considered.
Given the complexity of short and long-term disability insurance claims, you should contact a competent ERISA disability attorney like the ones at Murray Law Office if you are in need of help when you are denied and before you appeal. Even if you have not been denied, the short and long-term disability attorneys at Murray Law Office like to speak to clients as early as possible to warn them of many of the unknown surprises many clients run in to when filing a short and long-term disability claim on their own. We always provide a free initial consultation as we love educating our clients on how these claims work, warning them from the inception of their claim about the loopholes and exclusions which may be unique to the facts of their particular cases and disabilities that may limit their recovery, and (hopefully and most importantly) develop strategies to beat their insurance company.
If you are interested in a free consultation or want to speak to one of short and long-term disability attorneys at Murray Law Office CLICK HERE.
Murray Law Office takes pride in assisting our clients with the difficult legal issues facing them when they become disabled and when their ERISA governed claims for long, or short term disability benefits are denied or terminated.
This month, Jonathan T. Macedo of Murray Law Office, helped with a long term disability appeal for an ERISA governed matter for a Business Analyst who worked at a health insurance company. Our client was an exemplary individual who worked for many years while suffering from severe Dilatin induced neuropathy and complex regional pain syndrome.
Sadly, as our client’s health detreated and she progressively struggled to perform her occupational duties, she was the only individual from her group who was fired as a result of a “business reorganization.” To make matters worse, upon her termination, her employer informed her that her employer-provided benefits and coverage for her short and long term disability benefits had ceased due to her firing.
With Attorney Macedo’s assistance, our client filed for short and long term disability benefits. The insurance carrier originally denied her claim for short term disability benefits on the basis that she did not satisfy the “Actively at Work” provision of her employer’s self-funded short term disability plan due to her termination.
After appealing our client’s short term disability denial, Jonathan T. Macedo advised our client to exhaust her administrative remedies with respect to her long term disability policy which was insured by a long term disability carrier.
As our client was disabled at the time of her termination and did not become eligible for any other long term disability benefits from another employer within thirty one days, Attorney Macedo successfully argued that the “Actively at Work” provision as it pertains to long term disability benefits was not applicable as Massachusetts State Law requires her coverage to remain in effect. Accordingly, the insurance carrier was required to consider her application for long-term disability despite her employer’s incorrect guidance.
Unfortunately, after overcoming this hurdle, the insurance carrier next denied our client’s long term disability claim on the basis that the client could perform her sedentary occupation as a Business Analyst. In support of the insurance carrier’s long term disability denial, they used a single doctor’s office note where the client mentioned that she was sore all over due to the fact that she had just returned from vacation as justification as to why she had the ability to work.
Attorney Macedo appealed on the basis that the insurance carrier’s constant cherry-picking of the medical records in disregarding the client’s well-documented medical history of polyneuropathy and complex regional pain syndrome was arbitrary and that using a single one week vacation to justify the insurer’s denial of benefits violated Massachusetts General Laws Chapter 175, Section 108 which indicates that it is bad faith to make a distinction for lawful travel plans.
Finally, after working with the client for nearly two years applying for short term disability, appealing short term disability, applying for long term disability, and then appealing her long term disability denial, the insurance carrier finally decided to approve the client’s claim for long-term disability benefits. As a result, the client was able to receive nearly two years of retroactive benefits and was put on claim for future monthly long term disability benefits.
While every case is different as each individual’s short or long term disability policy and medical history is different, retaining a competent long term disability attorney for your ERISA governed claim who is barred in your state can be essential to your success and can be greatly beneficial in enforcing your right when pursuing your ERISA governed long term disability claim for disability benefits against a large national long term disability carrier.