Disability Insurance and ERISA Claims

Disability insurance provides peace of mind knowing that you and your family will have a stable source of income in the event of disability. What folks may not know is that not all disability insurance is the same. State law governs disability insurance purchased through an insurance agent; provided as part of a church sponsored employee benefits plan; or provided as part of a local, state, or federal government sponsored employee benefits plan. A federal law known as the Employee Retirement Income Security Act of 1974, or more commonly referred to as ERISA, governs almost all other disability insurance provided through employment.

What folks also may not know is how frequently claims for long term disability benefits (or LTD benefits) are denied. For example, we recently had a client suffering from chronic pain in his shoulders, neck, and back. Fortunately for him, he had disability insurance, which he had maintained and paid premiums on for many years. Unfortunately for him, when he could no longer work due to his condition, the insurance company denied his claim outright. When he complained on his own, the insurance company refused to offer him so much as a penny to resolve the situation. That is where we were retained. To make a long story short, after we filed suit, we ended up negotiating a large settlement with the insurance company.

At Weldon & Rothman, PL, we have experience handling long term disability benefits cases at the administrative level, as well as in Florida state and federal courts. In resolving claims, we have worked with many major employers and insurers, such as UPS, Verizon, MetLife, CIGNA, and The Hartford to name a few. While claims governed by state law allow us the opportunity to go straight to court to advocate for our clients, ERISA cases can be more difficult, as ERISA imposes many seemingly unfair burdens on disabled employees.

For instance, under ERISA, before going to court, disabled employees must first exhaust the administrative process provided for under the employer’s disability benefits plan. This process usually consists of the presentation of the initial claim followed by the opportunity for the disabled employee to appeal internally if the initial claim is denied. If the initial claim is denied, an attorney should be consulted immediately – even before the appeal of the claim denial is made – to ensure you protect the record for litigation. An attorney can help you prepare and submit your appeal, not only for the sake of the appeal, but for the sake of maximizing your chances in litigation should you receive a final denial letter.

Indeed, in ERISA cases, attorney involvement during the appeals process is crucial. Your administrative appeal is very likely the only time for you to introduce new evidence to support your claim. Believe it or not, once the decision on appeal is made, it is often too late to submit new evidence, meaning that even before your lawsuit has been filed, the record in your case may have already been created and sealed, and there is nothing you can do to change it. Think about it this way — if you have major surgery two (2) weeks after your final denial — if the surgery is not noted in your record, the trial court will never know about it. If you get hit by a car after your final denial, again, as far as the trial court is concerned, you are out of luck.

In an ERISA case, the road does not become any easier once you get to court. Here, the decision on your claim is often reviewed under a form of the “arbitrary and capricious” standard of review. The easiest way to understand the “arbitrary and capricious” standard of review is to know that even if the ERISA claims administrator (the decision maker on your claim) was wrong, you still lose so long as the decision of the ERISA claims administrator was reasonable based on the information before it at the time of the final denial. Only if the claim denial is found to be “arbitrary and capricious” or an “abuse of discretion” can you prevail on your claim. To stack the deck even further against you, during the appeals process – where the record on your claim is created and sealed – insurance companies contract with physicians to litter your file with written “peer review” reports, wherein the physician will review your medical records and readily agree with the ERISA claims administrator that your claim should be denied.

In sum, disability insurance is a rapidly changing and complex field. Long term disability claims are often denied without valid reason, leaving the disabled individual confronted with quickly mounting barriers to recovery. If you or someone you know is denied long term disability benefits, please call us immediately for a free consultation. We handle many long term disability cases on a contingency fee basis, meaning you are not responsible for any of our fees or costs unless we can obtain a financial recovery on your claim.

Let us help you attempt to recover your long term disability benefits. Please call us today. Have an attorney experienced in the area of disability insurance and ERISA litigation evaluate your case for free.

We pride ourselves on our service to and our exclusive focus on Southwest Florida: Naples, Ft. Myers, Sarasota, Bonita Springs, Estero, Marco Island, Immokalee, Port Charlotte, Punta Gorda, Cape Coral, Lehigh Acres, North Port, Bradenton, Collier County, Lee County, Charlotte County, Manatee County, and Sarasota County. We have convenient offices in Naples, Florida, Ft. Myers, Florida, and Sarasota, Florida. We concentrate all of our efforts on serving and advocating for the people of Southwest Florida. This means that your case will be handled by a local insurance lawyer who is available to meet with you in person, and who is familiar with the area’s legal community.

We appreciate the trust you have shown in our law firm. Let us help you achieve the justice you deserve. Please call us today for a free consultation.