ERISA CLAIMS — Disability insurance is designed to provide you with anywhere from 40-70% of your income, at the time of your disability. No matter if you become sick or injured and are unable to work, if you are disabled, the disability policy is there to support you.
If the disability insurance company denies your claim then it will be governed by the complex Federal laws of ERISA — an insurance company can simply deny a claim without fear of paying punitive damages if the denial is reversed upon appeal. It is extremely important that you contact a disability attorney for help. The appeal process and litigation process require an attorney that is ready to make sure insurance companies are held responsible. Many companies hope and rely upon the fact that many people needing care and suffering from a long term disabling medical condition will either miss some time or not have the strength to fight the insurance company for their benefits.
The basic idea is that the disability insurance purchase or funded by your employer, is designed to sell you security and peace of mind that you will be able to continue to provide for yourself and your family if you become sick or injured. This means the insurance company should be protecting your interests, not working against them.
Many employers have purchased a group plan, or help contribute to a group plan by either funding the plan through the purchase of insurance policies or the establishment of trusts, paid for by the employer or both the employer and the employee to that provide benefits to employees in the form of disability insurance, life insurance, medical insurance, severance benefits and pensions. This means that your rights to those benefits are governed by the federal statute 29 U.S.C.S. Section 1001 et. seq entitled Employee Retirement Income Security Act of 1974 – ERISA.
ERISA does not require that an employer provide health insurance to its employees or retirees, but it does regulate the operation of a health benefit plan if an employer chooses to provide one. Even if you have your own private health or disability insurance policy, it can be very stressful and difficult dealing with the insurance company about what is (and is not) covered and getting your bills and/or benefits paid. There have been several significant amendments to ERISA concerning health benefit plans: The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) provides some employees and beneficiaries with the right to continue their coverage under an employer-sponsored group health benefit plan for a limited time that would otherwise cause termination of such coverage.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) prohibits a health benefit plan from refusing to cover an employee’s pre-existing medical conditions in some circumstances. It also bars health benefit plans from certain types of discrimination on the basis of health status, genetic information, or disability. Other relevant amendments to ERISA include the Newborns’ and Mothers’ Health Protection Act, the Mental Health Parity Act, and the Women’s Health and Cancer Rights Act. If you have A PPO (Preferred Provider Organization) or a HMO (Health Maintenance Organization) the health insurance company owes you the duty of good faith and fair dealing. This means they must treat your claims in a fair, reasonable and quick manner.
Like disability insurance, life insurance is a way of thinking ahead and taking steps to protect your family from catastrophic events. In the event of the policy holder’s death, the insurance company will pay the decedent’s family the benefits of the policy so they can make sure to keep up with all their obligations during their time of need. If you are a part of a group life insurance plan issued by your employer, ERISA covers the way the claim is handled. This limits the benefits owed and the type of recovery the court can order, if the benefits are not paid.
If you have purchased a personal life insurance policy, the insurance company owes you a duty of good faith and fair dealing when reviewing the claim. The insurance company should handle you and your family’s interest as they would their own family. Unfortunately they don=t always do that.
WHAT TYPES OF INJURIES ARE COVERED?
Chronic Fatigue Syndrome
Arthritis, Carpal Tunnel Syndrome and many more.
WHAT YOU NEED TO KNOW ABOUT ERISA
ERISA law is governed by Federal Statutes and was established to set guidelines for employers to help protect employee’s benefits, such as disability, sickness and health concerns, retirement, welfare and other employment-related benefits. The legal guidelines are set forth in the Employer Retirement Income Security Act of 1974, otherwise known as ERISA (found in U.S. Code Title 29, Chapter 18). The application of ERISA is not an easily understood process. Unfortunately, many insurance companies fight against paying the benefits they owe at a time when people are most vulnerable, distraught and most likely to make mistakes.
Many people make the mistake of applying for disability benefits without thoroughly consulting their policy first. Your disability policy generally differs from other insurance policies, so it should be carefully reviewed. Your policy will define what your carrier considers to be disabled, how your benefits will be calculated, limitations on benefits, and most importantly crucial deadlines, just to name a few. A person must file an initial claim with the insurance company. A representative (a claims adjuster) will review the claim and make the determination to either pay or deny your benefits under the policy. If your claim is denied, you must file an appeal before a lawsuit can be filed. Missing a deadline or waiting too long to get help can mean the end of your claim. If a person accepts the decision denying the claim they will not receive any of the benefits they are owed at a time they need it most. If a person appeals the decision within the appropriate time frame they can have the insurance company review the claim again.
Every person is entitled to know what is contained in their claim file. The claim file is critical, because it is what the insurance company relies upon in making their determination about your claim. Before you appeal the denial, every person should attain a copy of the claim file from the carrier. It contains all the evidence the insurance company has to date, and what information they have gathered about you, including your medical records, the insurance companies own evaluations, surveillance if any, telephone call records, and a lot of other important information. In ERISA claims, this claim file will be the ONLY evidence a judge will look at to base their decision upon if you file a lawsuit. It is vital to know what is contained in your file. The claim file becomes the record for any potential lawsuit, so if you have not submitted the proper evidence, or the evidence is not in the file, you will lose and be denied the rightful benefits you are owed.
If you have received a letter denying your claim for benefits, the insurance company is obligated to provide the following information in denial letter:
1. the specific reason(s) for the denial;
2. references to the specific policy provisions on which the determination is made;
3. descriptions of additional material or information, if any, is necessary to make the claim valid;
4. explanations of what steps need to be taken to have the claim denied reviewed;
5. advisement of your right to bring a subsequent law suit under ERISA;
6. either provide or offer to provide any internal rules, guidelines or criteria that were relied upon in making the claims decision; and
7. how much time you have to appeal the decision denying your claim and the possibility that you could lose your right to do so if you fail to comply
If this information is not provided to you at the time of initial denial of your claim, a court may rule that the denial is incomplete and your appeal period has not yet started. However, DO NOT rely on this happening. If a lawsuit is filed and ultimately heard by the court, and the court agrees with you, the insurance carriers will be obligated to make the monthly payments they should have been making all along. In addition, the insurance company must pay all back money owed, before they improperly denied your claim. Further, the courts also have the discretion to award interest on past due amounts, as well as order the insurance company to pay attorney fees.
If you have been denied disability insurance coverage call us immediately at (818) 356-4747 for a FREE CONSULTATION.