Is My Long-Term Disability Claim Subject to ERISA Compliance Issues?

Chances are, if you have a long-term disability plan through your employer, then your policy is subject to ERISA compliance.

If you work for federal, state or local governments, Indian tribal entities, or churches, then you will not be subject to ERISA compliance.  This is an important distinction that can be very confusing when trying to figure out how your disability policy is governed, and whether it is covered by ERISA. 

ERISA, the Employee Retirement Income Security Act of 1974  is a federal law that sets the standards for long-term disability plans.  It protects you if you should become disabled and need long-term disability benefits.

Here’s what you should know about ERISA.

What ERISA Covers

Any employers who have employer-provided health insurance or retirement plans are likely to have policies covered under ERISA.
Along with other insurance policies, ERISA covers:

• medical, surgical, or hospital care
• benefits for sickness, accident, disability, or death
• unemployment benefits
• vacation benefits
• apprenticeship and training programs
• daycare centers
• scholarship funds
• prepaid legal services
• holiday or severance pay
• retirement plans

For the sake of this conversation though, and for what we can help you as a disability law firm, we are focused on long-term disability benefits. 

What You Need to be Aware of

ERISA administers most long-term disability policies.  The details of your policy and how it holds your insurance company to a set of standards for approving or denying your claim are nuanced.  A good long-term disability lawyer can help you to figure out the details of your claim, and if necessary your appeal.   

• Figure out what your policy’s definition of “disability” is: One policy may deem a disability to be a condition that keeps you from any employment, whereas another policy might say that a qualifying disability is one that keeps you from doing similar work to that which you had been doing prior to your injury or illness.  Consider a surgeon who loses the use of one hand.  If the policy said “any work,” the surgeon may not qualify because they could perform many other types of significant work.  Whereas if the policy said “like or similar work,” the surgeon indeed could not perform surgery and would probably be covered.  You can imagine, this is a common issue in many challenging long-term disability claims.  
• Be prepared to wait for your benefits. You will have an “elimination period” of between ninety to one hundred and eighty days between the time you become disabled and the earliest you become eligible for long-term disability.  Your employer may have provided you with short-term disability insurance to cover this gap.
• It is very important to have your medical records and doctors statements ready for review.  Keep everything!  Not just your medical records, but all your records relating to employment, HR stuff, accommodations, parking spot assignments, notes, all of it and more.  The reason – if you get into an appeal you need all the potential evidence you can find to stack the record on your behalf.  If your appeal is denied, your only recourse is a lawsuit which can only look into the evidence you had already submitted.  

• When and if you are approved you will only receive a percentage of your paycheck.  Long-term disability policies are not usually dollar for dollar replacements of your pre-injury income.  You should take this into account when figuring out your new budget. 

Updated ERISA Compliance Issues

The law surrounding ERISA covered long-term disability policies is not set in stone.  Rules and policies for claims, adjudication, denials, and appeals are updated and modified on a regular basis. 
For instance, here’s an update from 2016 that “Strengthens Consumer Protections for Workers Requesting Disability Benefits from ERISA Employee Benefit Plans.”
Highlights of this update include: 

• Denial notices must fully explain why you are denied. They must also discuss the basis for disagreeing with you or your doctors’ claim of disability.
• The denial notice must include internal rules, guidelines, protocols, standards, and such the plan used to deny the claim or state that none exist.
• You must be notified of your right to access and obtain copies of any documents or records about your claim.
• Before a final appeal decision, you must be given a reasonable opportunity to review and respond to any new or additional evidence.

Get Help!

Remember to be sure to review the specifics of your policy. And take a look at some of the sources cited in this article.  You can get a great baseline of knowledge from just a little bit of reading. 
After you have had a chance to understand your policy a little bit better, reach out to us.   Hiring an experienced Long-Term Disability lawyer will help you in your claim and appeal for benefits.