At first glance, Long-Term Disability Claims/Denials seem to be a simple issue of contract law. Usually, for the first 24 months, the definition of disability is whether or not you can perform your own job. So, if you can’t work, all you have to do is provide a form signed by your doctor that you are disabled and furnish “proof of disability” and magically the insurer will pay your claim!
So, why would anyone ever need a lawyer, let alone during the early stages of a claim? Seems simple, right?
Unfortunately, it is not simple. The Employee Retirement Income and Security Act (ERISA), which governs most of these claims, makes it more complicated.
That is why the attorneys at Quatrinini Rafferty are here to help you.
ERISA claims are not merely a breach of contract claim. The complex regulatory and administrative processes set up by the ERISA statute make ERISA claims substantially different from any other type of law. Without going into great detail, claims governed by ERISA are more similar to trusts than contracts. The insurers, rather than being on an even playing field, are in a much better position than the individual claiming disability in the battle for benefits.
This can certainly come as a shock to a person who has a serious medical problem, files the “paperwork,” expects to receive benefits under a “contract” for the payment of disability benefits, and is abruptly denied. Many of our clients apply for benefits on their own and assume, because it is obvious in their minds that they cannot work, that the insurance company will certainly approve their claim. In my 14 years of experience, this is the exception, not the rule.
This awful surprise is compounded by our clients who, once denied, try to appeal the denial of the Long-Term Disability carrier on their own. For a number of reasons, we encourage you to give our office a call if your Long-Term Disability claim has been denied. You should not try to represent yourself during the internal appeal stage (administrative appeal) or the appeal to federal court. There are critical deadlines that are often missed.
The appeal stage is the most important part of an ERISA-governed Long-Term Disability case. Why? Because when your claim (governed by ERISA) finally gets to Federal Court, the only evidence which the Court will consider is the evidence which was in front of the insurance carrier during the administrative appeals process.
I have looked at hundreds of cases throughout my 14 years of practice where an individual clearly had a severe disabling condition; however, they appealed the case on their own and, not knowing what to submit, failed to include critical information and medical evidence to support their claim, so they were denied by the insurance carrier. By the time this client shows up in my office to evaluate their case, too often the administrative record is “thin,” meaning that there is legally insufficient medical information or lay testimony to support their claim of disability.
Sometimes individuals show up in my office with information they assumed the insurance carrier received during the administrative appeals process. Can you imagine their shock when I tell them that the evidence would probably be barred in the Federal District Court litigation? Why? Because the information was not provided to the insurance company during the administrative appeals process (common examples include a diagnosis explaining the severity of the symptoms or a decision from the Social Security Administration finding the individual disabled). Yes, this is unfair, but it is the law.
To repeat – the administrative appeals process is the most important part of a Long-Term Disability claim governed by ERISA. You need one of our experienced, skilled Long-Term Disability advocates by your side as early as possible during the administrative appeals process. In fact, we file the initial application for many clients.
If you feel that you qualify for Long-Term Disability under your employer’s group policy or under your individual LTD policy, call us at (888) 534-6016 for a free legal consultation. The sooner the better!