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Long Term Disability Claims for Employer Provided Insurance

There are, generally speaking, two types of long term disability insurance policies.  There are “private” policies which are not obtained through employment.  There are also long term disability policies which are obtained as the result of employment.

If you have a long term disability policy through your employer’s group long term disability insurance, the odds are that it is considered an “employee benefit plan” which is subject to a federal law known as “ERISA.”  If you have a long term disability policy which is subject to ERISA, then the federal law known as ERISA, and the Department of Labor regulations applicable to ERISA, will apply to your claim.

If your initial claim for long term disability benefits was denied, you have certain rights under ERISA, including, but not limited to:

  • Filing an appeal of the denial with the plan administrator
  • Having at least 180 days after the denial to file an appeal
  • Obtaining all of the records and documents relied on by the plan administrator in denying the claim
  • Having an experienced disability insurance lawyer represent you in your appeal

Unfortunately, in many, if not most, long term disability policy lawsuits where ERISA applies, the standard for reversing the decision of the plan administrator is not favorable to the person whose benefits have been denied.  In many, if not most cases, that standard prevents the court from reversing the decision of the plan administrator unless the decision was arbitrary and capricious (also sometimes called the “abuse of discretion” standard).

The fact that the standard may be stacked in favor of the plan administrator if you file a lawsuit does not mean that you cannot win your lawsuit and recover long term disability benefits.  While you may need to file a long term disability lawsuit in federal court if you want to challenge a denial of an appeal for long term disability benefits, that lawsuit is likely to take substantially less time and work to resolve than a typical federal court lawsuit. It will more than likely be decided on cross motions for summary judgment and without the need for extensive discovery and depositions.

It is critical that, when your claim for long term disability benefits is denied, you consult with an experienced long term disability law firm promptly.  Besides the fact that there is a time limit for filing an appeal, what you don’t do in the appeal to the plan administrator may severely hurt your chances of winning a lawsuit if you have to file one.

While 180 days may sound like plenty of time to file an appeal, it is our experience that, in many cases, we need every bit of that time to obtain the plan administrator’s file; gather and review medical records; consult with treating physicians; and obtain letters and affidavits from medical care providers, vocational experts, and others.

You do not have to be totally incapacitated to be entitled to benefits for long term disability.   Lastly, if your policy definition of disabled requires you to be unable to perform the duties of any job for which you are reasonably trained and educated and not just the duties of your job, you still may meet the definition of disabled under the policy.  The “any occupation” definition of totally disabled has an earnings requirement.  In other words, if you cannot do your job, but can only do a job that doesn’t pay a certain amount (typically the amount you are entitled to for disability), you may still be considered disabled and entitled to benefits.