Do You Have an LTD Plan Governed by ERISA? You Need a Philadelphia ERISA Long-Term Disability Lawyer 

If you are a high income-earning medical professional and your only LTD coverage comes from your employer’s ERISA plan, we recommend that you sit down with a Philadelphia ERISA long-term disability lawyer at our national law firm as soon as possible to learn the details of your ERISA coverage and explore additional options, including the efficacy of securing individual disability insurance with specialty coverage for medical professionals. 

If you have a Long-Term Disability (LTD) policy provided as part of your employer-sponsored benefits plan, you might be surprised to find out that the coverage is not as robust or tailored to your profession or situation as you might think. Although some employer-sponsored plans are governed by the provisions of the Employee Retirement Income Security Act of 1974 (ERISA) — a series of laws enacted to protect policyholders — that does not mean you will be able to secure the benefits you are entitled to without a fight. One wrong turn during the process and you could be barred from receiving benefits altogether. 

ERISA includes a detailed procedural framework for filing claims, and missing one deadline can have disastrous consequences. Moreover, when the policyholder is a physician or other high earning professional, insurance companies often use certain tactics to avoid paying full benefits, or to deny or delay the claim. The help of a Philadelphia ERISA long-term disability lawyer can ensure that mistakes are avoided and that you receive your full compensation. 

If you are in urgent need of counsel either because you are in the process of making an ERISA long-term disability claim or if you have made a claim that has been denied, call our offices immediately as time is of the essence in securing your rights under your policy. 

Your Rights Under ERISA Law

ERISA is a series of federal laws designed to protect the retirement savings of America’s workforce, creating and enforcing standards of transparency and accountability that fiduciaries who manage those savings must meet. ERISA also protects the interests of employee health and disability benefit plan participants and their beneficiaries, requiring plan managers to meet certain standards of conduct and establishing enforcement provisions to ensure that plan funds are protected even if a company goes bankrupt.

ERISA requires each employee benefit plan to establish and maintain reasonable procedures for benefits claims and provide a guide to employees on how to file claims. As an ERISA policyholder, you not only have the right to file a claim, but ERISA guarantees you the right to appeal a denial or temination of benefits first through an administrative process and then, if necessary, through the federal court system. 

How Claims Work: Explained by a Philadelphia ERISA Long-Term Disability Lawyer

The first step in collecting ERISA long-term disability benefits is filing an ERISA claim. Not only must you carefully and thoroughly complete a series of forms, but your employer and your attending physician must complete forms as well. You must also allow the insurance company access to your employment and medical records, as appropriate, so they can evaluate your claim. 

Submitting the claim triggers the insurance company’s investigation into your disability claim. The claims representative will review all those claims forms you and your provider and employer filled out, all your medical and pharmacy records, and any relevant financial records. They will also take a close look at anything your physician has said or charted about your condition. The claims review process can take several months and may unfortunately result in the denial of your claim. 

Our Philadelphia ERISA Long-Term Disability Lawyer Explains Common Reasons for Denial of LTD Claims 

Some disability insurance companies will claim that the physician can still do aspects of his or her specialty and is therefore not entitled to full benefits. The insurer may attempt to shorten the duration of the claim and reduce the benefits owed. Some policies provide that if a person becomes totally disabled before a certain age (often 55), then benefits are payable for life. To avoid paying lifetime benefits, the insurance company may argue that the physician was only partially disabled at age 55.

Other common reasons for denying LTD benefits are that the claim was not timely filed, that inadequate documentation was provided, or that the insured failed to cooperate with the claims investigation. A Philadelphia ERISA long-term disability lawyer will be familiar with all of the tactics and strategies disability insurance companies try to use against medical professionals and can advocate on your behalf so that you can receive the benefits to which you are entitled.

In their denial of your claim, the plan administrator must provide you with: 

  • A detailed explanation of why your claim was denied, including an explanation of why the plan disagreed with the views of a medical professional or vocational expert and/or a disability determination made by the Social Security Administration, where applicable;
  • A reference to the specific plan provisions on which the denial is based; 
  • The ability to secure all documentation used by the plan administrator in making their determination;
  • Which of the plan rules, guidelines, protocols, standards, or other similar criteria they relied upon in making the determination to deny the claim; and 
  • Information about how to pursue an appeal, including the plan’s appeal process, the time limits involved, and an acknowledgement that you have the right to pursue your claim in court should your claim be denied on appeal. 

The precise terms of your policy coverage and how those terms are interpreted, as well as the record established to substantiate your claim, are all critical to the appeals process. If you get to the stage of claim denial and are not already working with a Philadelphia ERISA long-term disability lawyer, we strongly encourage you to contact our offices before moving forward. 

ERISA Appeals and ERISA Litigation

If you receive a denial of benefits under an LTD plan subject to ERISA, then you have 180 days to file an appeal. Meeting this 180-day deadline is crucial. If you miss it, your rights to benefits are lost. Some plans even require two appeals. And while ERISA allows plans to mandate two appeal stages, it also provides that plans cannot require a claimant to file more than two appeals prior to bringing a civil action.

It is critical that you work with a Philadelphia long-term disability lawyer when filing your appeal. Not only will the lawyers at the national law firm of Seltzer & Associates make sure the filing deadline is met, but we will also make sure that your appeal is as well thought out and thoroughly supported as possible. You only get one chance to provide evidence and arguments supporting your appeal. While a denial of your appeal is not your final recourse — you can still take the case to court — only evidence provided at the administrative appeal level will usually be admissible in your court case. 

A determination about your appeal should be available within 45 days, but the law allows for a 45 day extension for a total of 90 days. If your appeal is denied, your only remaining option is to file a lawsuit against the insurance company that denied your claim. 

ERISA litigation is handled in federal court. As previously mentioned, the court will most probably only review the evidence you submitted during the appeals process — usually no new evidence, no matter how compelling, can be introduced at this time. And even if your appeal was erroneously denied, or the court finds that you are duly entitled to be paid benefits, you cannot hold the insurance company responsible for any alleged bad faith or the pain and suffering you experienced as a result. 

How a Philadelphia ERISA Long-Term Disability Lawyer Can Help with Your Claim

Your entire case — and likely your financial security — rests on the record you create as you work your way through the claims and appeals processes. Because no new evidence can likely be offered at trial, it is important to have your Philadelphia ERISA long-term disability lawyer by your side throughout the process, ideally at the beginning stages when you file your claim, but certainly before you file any appeal. By engaging professional ERISA counsel at the outset, you will avoid the mistakes that can result in a denial of your claim. For example:

  • Do not rely on your employer’s human resources department to interpret your long-term disability insurance policy benefits and advise you on how to proceed. HR people, while well-meaning, are not experts in LTD law, nor are they equipped to interpret complex insurance policy language. 
  • Do not exclusively use the forms supplied by the insurance company to document your claim. There is sure to be critical information supporting your claim that does not fall within the four corners of a boilerplate form. Insist that your physician complete a thorough report about your disability (your Philadelphia ERISA long term disability lawyer can do this on your behalf).
  • It is better to secure private Social Security Disability counsel to help you with your Social Security Disability claim rather than hire counsel referred to you by your insurance company to assist you with obtaining your Social Security Disability benefits. While you will likely be required to file for Social Security Disability during the course of your LTD claim, the insurance company representatives are engaged to make sure that the interests of the company are best protected (and not yours) in not only getting the company the Social Security Disability benefit offset they seek, but also possibly having access to information and direct uncounseled contact with you which they may attempt to use to compromise your claim.  

ERISA law is complicated and filing for LTD claims in accordance with all the required rules and regulations can be difficult and very challenging.  Choose an attorney with ERISA long-term disability claims experience. 

Which Types of Policies are Typically Not Covered by ERISA?

Although ERISA governs most private LTD benefits, it generally does not apply to individually purchased private disability policies. Nor does it cover employee benefit plans offered through public employers. Employers of public schools, including state universities, are generally exempt from ERISA.

A group disability insurance policy is covered by ERISA if the plan is employer-sponsored, established by the employer or an employee organization, to provide disability benefits. ERISA may not govern a plan if the employer makes no contributions to the disability insurance policy and participation is completely voluntary.

ERISA claims are especially difficult to navigate without the help of an experienced  Philadelphia ERISA long-term disability lawyer.

Contact a Philadelphia ERISA Long-Term Disability Lawyer

Whether you are a medical professional wondering if your ERISA policy adequately provides for your needs, are about to file a claim under your policy, or are in the appeals process, please contact a Philadelphia ERISA long-term disability lawyer at our national law firm. We offer worry-free, no-cost consultations. Please reach out to us either online or by calling our office at 888-699-4222.