ERISA is a federal law with sets the minimum standards for most voluntary, private pension and healthcare plans, including coverage for short- and long-term disability. ERISA requires employers provide employees certain information regarding their plans, including how to file a claim, what happens if the claim is denied, and rights to file a lawsuit if the insurance company denies their claim for benefits. Many individuals have a number of questions regarding ERISA disability claims and what to do if they are denied.
Is my Disability Plan Covered by ERISA?
Not all disability plans are covered by ERISA. ERISA specifically applies to voluntary, private disability insurance provided by the company. Generally, most employer-sponsored group plans that provide long-term and/or short-term disability are included.
However, if the employer makes no contribution to a disability insurance policy, or the plan is completely voluntary, such plans may not be covered by ERISA. A program that allows workers to contribute to their disability insurance program by taking contributions out of payroll may not be included where the employer is not actively involved in the plan.
Government employees and those receiving church benefits are also generally not included in ERISA plans. Employees who purchase their own disability insurance are also not included; however, these plans may be protected by other regulations under state or federal law.
Some states require employers to provide disability insurance for their employees, including California, Hawaii, New Jersey, New York, and Rhode Island. In these states, ERISA may not apply to disability benefit claims because they are mandated. However, these states may have their own regulations to protect employees.
Some individuals may work in a contract capacity with a government agency or private company and are unsure if they may be covered by ERISA, or not. If you have are unsure whether your disability insurance is covered by ERISA, you can request a copy of your plan summary from your human resources department. If you have been denied disability benefits, talk to an experienced disability benefits attorney to determine your rights and protections.
Is my injury or illness considered a disability?
Whether a disability is covered by your disability insurance claim will depend on the illness or disease, specific disability plan, and if the disability is short-term or long-term. Each individual plan spells out the requirements for filing a disability claim, and may specifically exclude certain types of conditions that are not covered by insurance. These terms and conditions may be included in the plan's Summary Plan Description (SPD) or Summary of Benefits and Coverage (SBC).
Review your specific plan for disabling injuries which may not be included. This may include elective surgery, cosmetic surgery, self-inflicted injuries, or injuries resulting from the commission of a felony.
Is pregnancy covered even though it is not a disease or disability?
Pregnancy is not a disease or illness; however, short-term disability benefits may be available for workers on maternity leave. Short-term disability may provide benefits to cover a portion of the worker's salary during the time they are unable to work due to pregnancy, childbirth, and post-pregnancy recovery. Individuals should review their plan to understand what their plan covers related to pregnancy leave.
What is the difference between short-term and long-term disability?
Some employers offer short-term disability or long-term disability, or both. Short-term disability provides benefits for individuals who are temporarily ill or injured and unable to work. These policies generally provide coverage for up to 3 to 6 months. If an individual is covered by both types of disability insurance, they may be able to seek long-term benefits if they are still disabled after short-term benefits run out.
Long-term disability generally applies to disease, serious injury, or debilitating illnesses that keep the individual from returning to work for months or years. In some cases, a long-term injury will prevent them from returning to work every again. Long-term benefits may last until the individual reaches the age of retirement.
The claim process for short- and long-term disability is similar, involving filling out forms and submitting medical records. However, insurance companies may scrutinize a long-term disability claim much more closely. In some cases, an individual approved for short-term disability but they are later denied long-term disability coverage even though they may still be unable to work.
What happens after my claim is denied?
After filing a claim for disability, the insurance company has a reasonable time to respond but not longer than 45 days. In some cases, the insurance company can seek a 30-day extension to respond. If the claim is denied, the insurance company has to provide specific information as to the basis of their findings. They are also required to provide information on how to appeal the claim.
In most cases, the employee has 180 days to file an appeal. Many individuals contact an attorney before filing an appeal to protect their interests during the appeals process. An experienced ERISA disability attorney can identify problems with the application, address concerns from the insurance company, and submit additional information to support the disability claim.
What happens if my appeal is denied?
After filing an appeal, the insurance company has 45 days to respond, plus an additional 45-day extension in special circumstances. If the appeal is denied, the individual may be able to take legal action against the insurance company.
An ERISA disability attorney will be able to file a lawsuit against the insurance company in federal court. The lawsuit may seek damages to include disability benefits, reinstatement of benefits, payment for past benefits, and legal costs. The case could proceed through litigation to a trial; however, most cases are settled before they reach the trial stage.
Do I need an attorney?
An ERISA disability benefits attorney will represent your interests and fight to get you the benefits you deserve. In many cases, an ERISA attorney will offer a free consultation to evaluate the case.
Greg Paul has 18 years of experience fighting for long-term disability benefits against the insurance companies. We represent individuals and families who have been denied benefits by their insurance company or plan administrator. You have a limited time to appeal your disability denial, so do not delay. If you have been denied short-term or long-term disability benefits, contact our office for a free consultation.