• David Manes

Long-term disability benefits and ERISA

Workers are often granted short-term disability benefits from their employer’s insurance company for a variety of illnesses and conditions. A worker may have fractured her leg while at work, contracted a debilitating virus or been diagnosed with a new medical condition. Oftentimes the threshold for being granted short-term disability benefits is not that high, but in order to be granted long-term disability benefits the obstacles are much more substantial. Long-term disability benefits can be extremely expensive for insurance companies; therefore they will often deny them initially except in the most egregious of circumstances. The law that governs the granting of these long-term disability benefits is called the Employee Retirement Income Security Act (“ERISA.”)

ERISA and long-term disability

ERISA does not require that employer’s provide health insurance or disability insurance plans to their employees, but if an employer chooses to provide these plans, ERISA regulates how these plans work. Most importantly, ERISA provides an avenue of appeal through the federal courts in case your application for long-term disability has been denied.

What to do if my application for long-term disability has been denied?

If your initial application was denied your insurance plan is required by ERISA to give you an opportunity appeal the claim. This appeal can be very complicated and there are several steps that you will want to follow to make sure your appeal is strong.

Gather your records

Your insurance company will have gathered most of your medical records in order to evaluate your initial claim, but you will want to fill in the blanks with all additional medical records and evidence that you may have. In order to do this request the files from your insurance company and identify any records that may be missing. Then request the missing records from your doctors and add them to your appeal. This can be a crucial step because oftentimes an insurer will leave out some of the most important evidence for your case.

Have additional testing done

Insurance companies rely heavily on objective evidence when evaluating the legitimacy of your claim. Sometimes certain tests have not been performed that can help you win your case. This is especially true if you suffer from a mental or psychological condition. You may need to have cognitive testing done to provide objective evidence that your psychological condition affects your ability to work.

Create a persuasive narrative

Insurance companies will deny benefits for a variety of reasons and in order to win on appeal you must develop a persuasive narrative. For example, oftentimes insurance companies will overlook certain conditions that you may suffer from, or they will only look at a single illness in isolation. You may want to argue that in isolation a single condition does not make you disabled, but when all of your illnesses are viewed in combination, the disability is total. Finding a strong narrative to frame your case can help you win your benefits.

When to contact an attorney

If you have been denied after your initial application it is probably time to contact an attorney. The earlier that your lawyer can begin developing your case the better the chances are that he will be able to win. Gathering evidence and developing a compelling narrative can take a long time, so get a lawyer on board as soon as possible. For advice and a free consultation concerning your ERISA long-term benefits case, please call Kraemer, Manes and Associates at (412) 626-5626.

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