Our law firm represents clients that have either group or private disability policies. Most group disability policies (also known as ERISA policies) are governed by a very complex federal statute called the Employees Retirement Income Securities Act, (“ERISA”). An individual usually has a group disability policy, if they received the disability policy as an employee benefit from an employer or purchased the policy from a trade association that offers the discounted disability income policy to it’s members..
ERISA /Group Policies Are Different From
Private Policies In Several Significant Ways.
First, with a private policy if your insurance carrier denies your claim, you usually have the right to file suit and begin to gather your evidence. However, with most group policies you must submit an appeal, within a specified time period, directly to the insurance company prior to filing suit. This requires gathering all of the evidence that would be helpful at trial and submitting it with your letter of appeal. In order to present our client’s case in a light most favorable to the insured, we work very closely with our clients and their treating physicians, to insure that the appeals are submitted with an overwhelming amount of information and detail. A well document appeal is essential in order to have a chance of being successful at an ERISA non-jury trial.
Second, unlike a private policy claim, an ERISA disability insurance case is heard in federal court without a jury. There is usually no testimony by the insured, experts, or physicians. The evidence is limited to the documentation provided during the application stage, documents contained in the Appeal, and previously gathered information by the insurance carrier. We prepare all of our appeals in anticipation that the case may go trial in the event an Appeal is denied.
Third, unlike a private claim at trial you are not attempting to prove that you are in fact disabled. The test is much more stringent. The insured has the burden of showing that given all the evidence submitted by the insured and gathered by the insurance company, there is no reasonable way that the insurance company could have determined that the insured is not disabled.
ERISA provides extremely strict guidelines and deadlines for disabled claimants seeking disability insurance benefits under their group policies. If information is not submitted within these timelines, a claimant may be forever barred from introducing the documentation to prove their disability. Moreover, group disability income policies are drafted with ambiguous and confusing contractual terms. These ambiguities provide insurance companies with multiple reasons for delaying and denying disability income benefits. Furthermore, most policies provide the insurance company with full discretion in deciding whether sufficient information has been provided by claimants prior to approving a claim. Given the complexity of the legal issues involved and the tendency of insurance companies to vigorously defend claim denials, evaluation of any potential legal claim on behalf of an insured should be handled by a law firm experienced in insurance claims.
We are available to provide you with a free consultation and review of your disability policy. Please keep in mind that there are time deadlines with ERISA claims and we must have sufficient time to evaluate your claim and take the appropriate legal actions.
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Chiropractor Placed on Claim Despite a “Any Occupation” Provision
Our client, a chiropractor, suffered from severe bilateral carpal tunnel syndrome, as a result of a traffic accident. Our client applied for disability insurance benefits under the terms of his contract. His disability insurance contract defined total disability for the first 24 months as the inability to perform the substantial and material duties of his occupation as a chiropractor. After 24 months the definition changed to the inability to perform the substantial and material duties of any occupation taking into consideration his education, training, experience, and pre-disability earnings. Earnings were defined as “income from work.”
Our client was paid for the first 24 months, however thereafter his insurance carrier denied further benefits, claiming that our client could engage in several other occupations and was thus, no longer disabled. His insurance carrier asserted that since our client did not withhold Social Security from the profits he obtained from his practice, the money received was deemed “dividends” rather than “income / earnings.” Therefore, the insurance carrier considered his pre-disability earnings as $0, despite the fact that he was earning upwards of $200,000 per year. As such, the insurance carrier argued that if he could engage in any job in which he could earn more than $0 per year, he was not eligible for total disability benefits.
We submitted an appeal to the insurance carrier providing ample medical documentation, a report from a vocational rehabilitation expert, and citing applicable case law. Based on our appeal, our client’s insurance carrier reversed its decision, provided all back benefits owed, including interest, commenced monthly benefits, and paid attorney’s fees and costs.
Source:
Disability Attorney Insurance Disability Benefits Lawyer
When an individual buys a disability income policy from an insurance company, the individual and the insurance company enter into a signed contractual agreement. If an individual is disabled according to the terms of the disability income policy, the carrier must pay the claim. The insurance company’s failure to pay benefits is a breach of contract.
If your claim for disability benefits has either been delayed, denied, or your monthly benefits have been cut-off, our law firm can provide you with multiple options. Most denials of benefits do not require the filing of a lawsuit against the insurance company. In many cases our law firm will open the lines of communication with the insurance company and have a claim re-evaluated. Additionally, we will submit a detailed demand letter, which addresses the medical and legal issues and strengths of your claim, thereby giving the insurance company a last chance to pay benefits prior to the filing of a lawsuit.
Some disability policies require the filing of an appeal before a lawsuit can be filed. We regularly file appeals for individuals and for claimants that have group disability policies that were issued by their employer. In many cases we are able to mediate and meet with the insurance company in order to secure benefits without the need to file a lawsuit. If our investigation of a claim reveals that the insurance company did not have a good faith basis for the denial of our client’s claim, we will file a Civil-Remedy Notice with the appropriate State Department of Insurance and Finance.
The final option is to file a lawsuit against the insurance company for breach of contract in either state of federal court. Our firm has litigated multiple cases against every major disability insurance carrier in the country. We have extensive knowledge and experience regarding any all defenses that the insurance companies will raise in attempt to not pay disability benefits. Furthermore, insurance companies respect our law firm’s abilities and are aware that we are relentless in the pursuit of our client’s claim.
All of our litigation clients are represented on a contingency fee basis, which means we do not charge any attorney fees or cost unless we make a recovery for our clients. Disability income lawsuits are very heavily litigated and require hundreds of hours of time. Due to the complexity, risk and hours involved in litigating a disability claim, we intentionally limit the number of cases we handle and are selective in the cases that we pursue for litigation. Uniformly, in disability cases we realize that our client’s future source of income is at stake, and we are committed to quickly obtaining disability benefits that have been wrongfully denied by an insurance company.
If your claim has been denied, you are waiting for a claim decision, or your monthly benefits have been cut-off, we will provide you with a free consultation and evaluation of your claim for disability benefits.
Source: Dell & Schaefer
