If you have long term disability insurance through your employer or union, it is subject to the Employee Retirement Income Security Act or ERISA. This does not apply to those employed by the government or a religious institution. There is no easy, quick explanation of ERISA, but our years of commitment to employee benefits can guide you through the ERISA long term disability claims process.
Working to Secure Benefits for Our Clients Under ERISA
ERISA is a federal law governing employee benefits provided by private sector employers. This law is complicated and often contested. If your long-term disability policy is under ERISA, you should retain an ERISA long term disability lawyer.
Jonathan M. Feigenbaum, an ERISA long term disability lawyer, has spent his legal career helping people file for disability benefits. He knows how to decode the complex language of insurance policies in order to secure the benefits you need. He can assist you in your pursuit of benefits under Section 502 of ERISA, 29 U.S.C. §1132.
An ERISA Long Term Disability Lawyer in RI Expands on the Legal Meaning of Disability
Legal disability is an elusive concept. Policy makers often define disability as the inability to perform work due to an impairment arising from a medical condition. Similarly, the United States government characterizes disability as the inability to perform work, or the reduction in capacity to work.
The medical condition causing the impairment may be temporary, permanent, or chronic. The person is disabled when the medical condition and resulting impairment prevents the individual from working. Above all, determining disability requires combining a medical as well as vocational analysis with a legal definition.
Definition of Disability in Insurance Policies
Disability insurance policies are generally classified as:
- “Own occupation.” To be disabled under these policies, the policyholder has to show he or she can’t do the material duties of his or her own or regular occupation. Some of these policies define own occupation very narrowly, e.g., a medical doctor within a particular specialty or sub-specialty.
- “Any occupation.” To be disabled under these policies, the policyholder has to prove he or she cannot do any occupation. In general, these policies include language stating that any occupation means any occupation to which the individual is suited by education, training or experience.
- “Any gainful employment.” To be disabled under these policies, the policyholder has to show he or she cannot engage in any gainful employment. Gainful may be defined as employment that pays the policyholder at least a certain percentage of the salary he or she was earning before becoming disabled.
The blended versions of “own occupation” and “any occupation” policies focus on “loss of earned income”. These policies provide benefits if an insured suffers a loss of earned income due to disability.
Restrictions and Limitations
In ERISA long-term disability cases, a claim often receives approval or denial based on the insurer’s perception of your functional impairment, using insurance-medical terms called “restrictions” and “limitations.” “Restrictions” mean activities that you cannot do, whereas “limitations” mean activities that you are able to do but not with the same frequency, intensity, or duration that you could before suffering an injury or sickness.
Medical doctors do not use these terms in their daily practices. Educating your doctor about the importance of expressing his or her opinion regarding your medical condition in terms of “limitations” and “restrictions” may be necessary. Simply saying, “My patient Jane Doe is disabled and cannot return to work at this time,” will almost always result in the insurer denying your claim. An experienced ERISA long term disability lawyer in RI can help you with all of the legal details that can potentially result in the awarding of benefits.
The legal complexity of disability arises from linking a medical condition to impairment. For example, a person could suffer the loss of a lung as a result of disease. That loss is measurable as well as observable. A person with little medical or impairment training can readily understand the disabilities associated with having only one lung. Missing a lung would not, however, automatically equate with disability. For example, having one lung limits a person from working as a salvage diver. Yet a person with that same limitation could probably work as an insurance agent or broker.
The salvage diver’s entitlement to disability benefits depends on how his or her policy defines disability. Whether the policy is subject to ERISA also comes into play. ERISA and individual policies share one thing in common – the lack of a uniform, consistent and unwavering standard of disability.
How the Insurance Company Will Investigate Your Disability Claim
When you apply for disability insurance benefits, the insurance company will investigate your claim. Its investigation will focus on your medical conditions, your functional abilities and work background. It is important to cooperate with the insurance company during this investigation. If you fail to complete forms or cooperate, your claim may be denied.
You Will Complete Questionnaires and Forms
A disability insurance claim involves a lot of paperwork. You, your doctor and your employer will complete a series of forms. These forms may ask questions about your:
- Medical conditions and symptoms
- Doctors and other medical providers
- Medical treatment and medications
- Job duties and responsibilities,
- Education and work experience, and
- Daily activities and hobbies
It is important that you give accurate information on these forms. Do not overstate or minimize your symptoms. The insurance company will review your forms as part of their claims investigation. If you provide inaccurate information, they may become skeptical of your claim and deny benefits.
For example, disabled workers often list chores and hobbies that they used to do on daily activity or function reports. The insurance company may decide that you can work, based on an assumption that you are performing frequent, heavy chores.
Make sure you complete and return the forms promptly. Failure to complete forms can result in a denial of benefits.
The Insurance Company Will Review Your Medical Records
You cannot win a disability claim without medical evidence. Disability is typically defined as an inability to work due to medical conditions. Unfortunately, the insurance company will not approve a claim that is only based on your description of symptoms.
Instead, the insurance company will review all of your medical records, looking for evidence of disability. Objective, or fact-based evidence (like an MRI or x-ray report) is particularly important in a disability claim. If you have diagnostic studies or testing that supports your diagnosis, make sure the insurance company gets copies of these records.
The insurance company cannot get your medical permissions without your permission. You will have to sign a medical release (sometimes called a HIPAA release). You can withdraw or cancel a medical release at any time. Also, you can send copies of your medical records directly to the insurance company.
Once the insurance company has your medical records, they will review them. Sometimes, an insurance company doctor will review your records and recommend work restrictions. Other times, an insurance adjuster will review your claim.
The Insurance Company May Send You to a Medical Examination
During the claims process, the insurance company may send you to an independent medical examination (IME) or a functional capacity evaluation (FCE). The insurance company will pay for these exams.
An IME is a medical examination focusing on disability. A doctor (chosen by the insurance company) will interview you and perform an exam. An IME typically takes an hour (or less) to complete. After the exam, the doctor will issue a report. This report will typically discuss your symptoms and review your medical records, as well as give a series of diagnoses. Sometimes, an IME report will also include work restrictions.
An FCE is a series of tests that assess your ability to work. An FCE is considered an objective (or fact-based) test. For this reason, an FCE carries a lot of weight with insurance companies and judges. An FCE usually takes between four to six hours and requires physical activity. After an FCE, the examiner will create a detailed report assessing your physical abilities. An FCE report almost always includes a set of work restrictions.
If you are scheduled for an IME or FCE, you must attend the exam. If you refuse to attend the exam, benefits may be denied. Additionally, make sure you are honest during the exam. Do not exaggerate your symptoms, since the examiner will note the exaggeration in his or her report. Exaggerated symptoms can lead to an invalid report and a denial of benefits.
Similarly, do not minimize your symptoms. If you overstate your abilities, the doctor may think you can return to work. This may also result in a denial of benefits.
The Insurance Company Will Perform a Vocational Analysis
Once the insurance company has most of your medical information, it will decide whether work restrictions are appropriate in your case. Your work restrictions can involve both your physical and mental capabilities.
After the insurance company has decided on a set of work restrictions, it will perform a vocational analysis. A vocational analysis determines whether your restrictions allow you to work.
ERISA plans typically define disability in two ways:
- Own Occupation: You have a disability if your medical conditions stop you from doing your job, and
- All Occupations: You have a disability if your medical conditions prevent you from doing any work.
Your Summary Plan Description (SPD) will include your plan’s definition of disability.
Depending on your plan, the insurance company will compare your restrictions to either the job you performed or a variety of jobs within the national economy. If the insurance company believes you are capable of working, your claim may be denied.
The Insurance Company Will Review Your Information and Issue a Decision
Based on its medical review and vocational assessment, the insurance company will issue a decision either approving or denying benefits. It can take months before a decision is issued.
If your disability claim is denied, the insurance company must give an explanation of why your benefits were not approved. The denial letter must also explain the appeal process.
If Your Disability Insurance Claim is Denied, You Have the Right to Appeal
If your disability insurance claim is denied, you should contact an experienced ERISA lawyer immediately. ERISA appeals often have strict filing and evidentiary deadlines. If you miss these deadlines, you may lose your right to benefits.
An experienced ERISA lawyer can evaluate your claim, as well as guide you through the appeal process. Do not delay in contacting an ERISA lawyer — preparing a disability claim for appeal takes time. Your lawyer will need to review the insurance company’s extensive file, request additional information and prepare written arguments.
Contact ERISA Lawsuit Lawyer, Jonathan M. Feigenbaum, Esquire
We offer free initial consultations. For assistance with your claim, contact ERISA lawyer Jonathan M. Feigenbaum, Esquire. Reach us by phone at 617-357-9700 or 866-396-9722 (toll-free), or through our How Can We Help form.