Our Philadelphia ERISA Disability Attorney Explains if You Have a Claim

The Employee Retirement Income Security Act of 1975, or “ERISA,” is the federal statute that governs certain employee benefit plans. Generally, ERISA applies to all long-term disability insurance policies you receive through your employer. However, it is ultimately a matter for a court to decide. Thus, you will need to hire a Philadelphia ERISA disability attorney if you believe you are a victim of a violation. 

What exactly is ERISA coverage? 

Most long-term disability plans are governed by the Employee Retirement Income Security Act (ERISA), a complex federal law enacted to protect employee benefit plans and beneficiaries’ interests and sets rules for private sector employee benefit plans. While ERISA protects the rights of employees to seek disability benefits and provides legal remedies when employers refuse coverage, it is important to understand the scope and extent of your LTD coverage, as well as policyholder rights and obligations when pursuing a disability claim. A Philadelphia ERISA disability attorney can help.

ERISA is administered and enforced by the U.S. Labor Department’s Employee Benefits Security Administration, the Treasury Department’s Internal Revenue Service, and the Pension Benefit Guaranty Corporation. A Philadelphia ERISA long-term disability lawyer can advocate on your behalf before any or all of these agencies.

What Happens in an ERISA lawsuit? 

The federal courts have exclusive jurisdiction over ERISA cases. If it is clear that ERISA applies to your claim for benefits, you must file your lawsuit in a federal court with proper jurisdiction. Typically, this can only be done once all administrative remedies have been exhausted, including any mandatory appeal(s).

The rules of ERISA litigation differ from general civil litigation in some key areas. For instance, jury trials are disallowed in ERISA cases, and extra-contractual damages and punitive damages are not available. ERISA is very specific as to any damages allowable in these cases. Furthermore, ERISA does not allow for bad faith causes of action, which are available under most individual disability policies. For these reasons, group LTD insurers do not face the same potential financial repercussions in dealing with the ERISA-governed lawsuits against them.

Unfortunately, most ERISA plaintiffs must also overcome a heightened burden of proof known as abuse of discretion. This means your ERISA disability lawyer must demonstrate that the insurer’s denial or termination of benefits was “arbitrary and capricious.” A court will only order an insurer to reverse its denial or termination when the claimant has met his or her burden of proof. The abuse of discretion review applied in most ERISA cases makes meeting the burden of proof requirement significantly more difficult for claimants. In many ERISA matters, the burden of proof alone may determine the outcome of the case.

Claimants with group LTD coverage should always be mindful of the numerous disadvantages inherent to litigating ERISA-governed claims. It is extremely important to have legal counsel in these cases because of the additional complications created by ERISA, the difficult standard of review, and the volume of court decisions that exist in long-term disability insurance companies’ favor.

The ERISA Claims Process Explained by an Experienced Philadelphia ERISA Disability Attorney 

In the simplest terms, the ERISA process boils down to four main steps. If your claim for disability insurance benefits is approved in step two, then you would not need to file an appeal (step 3) or lawsuit (step 4): 

  1. File your disability insurance claim with your Philadelphia ERISA disability attorney.
  2. Await an investigation of your claim by the insurance company to determine if you qualify for disability insurance benefits.
  3. If your claim is denied, a Philadelphia ERISA disability attorney can help you with the appeals process. 
  4. If your appeal is unsuccessful, you and your Philadelphia ERISA disability lawyer can file an ERISA lawsuit.

What Claimants Need to Know

ERISA litigation is difficult to navigate, sometimes even for the most experienced lawyers. Working with a Philadelphia ERISA disability attorney at Seltzer & Associates ensures you are taking the right steps to preserve your rights and maximize your chances of being awarded benefits without requiring an appeal or a lawsuit.  

When to Turn to a Philadelphia ERISA Disability Attorney

At Seltzer and Associates, we encourage everyone to contact a law firm that specializes in disability claims when pursuing benefits. That said, ERISA claims are particularly complicated, thus an attorney is more or less a requirement. Reasons ERISA long-term disability lawsuits are complicated are: 

  • An individual simply lacks the understanding of the ERISA rules and loopholes that an insurance company has.
  • ERISA insurance claims typically require a substantial amount of medical evidence that is more easily collected with the help of an ERISA disability attorney.
  • You may need to also apply for Social Security benefits, but loopholes can prevent you from receiving SS benefits as well as ERISA disability insurance benefits. 
  • Denied ERISA claims often require that you “exhaust administrative remedies” before you can file an appeal.
  • ERISA lawsuits are often filed in federal court and require the extensive knowledge of an experienced ERISA disability attorney. 

Understanding ERISA Deadlines

Long-term disability insurance policies allow the insurance company to periodically reevaluate approved claims. During this review process, insurance companies look at the policy terms and examine changes in medical conditions as well as the duration of the claim. The insurance companies will look to any limiting policy terms that will afford a reasonable basis to terminate the claim.

ERISA provides covered claimants the opportunity to review the insurer’s entire record or claim file when a claim is denied or terminated. After reviewing the record, termination notices, and written explanations, the claimant has the right to appeal the insurance company’s decision, but this must be done within the timeframe allowed under ERISA

Deadlines apply on both sides of the long-term disability insurance equation. After a denial, you should request the claim file as soon as possible. Your Philadelphia ERISA disability attorney will keep you apprised of all deadlines to ensure you do not waive your right to appeal an adverse decision regarding your disability insurance claim.

We want you to know the process is complex, and it can be long and arduous. ERISA outlines specific rules for claimants, including:

  • If you miss a deadline, you may lose your right to receive disability insurance benefits.
  • If you appeal your disability insurance claim denial you must present all the evidence in the appeal process because you may not be allowed to present new evidence during litigation.
  • Administrative records are reviewed by a Judge, not a jury.

Our Philadelphia ERISA Disability Attorney Offers Free Initial Consultation for ERISA Claims

Seltzer & Associates provides an initial consultation with a Philadelphia ERISA long-term disability lawyer free of charge. Whether you need to file a claim or have had a claim denied or terminated, we can review your policy and documents for you without obligation. We will review the issues specific to your situation, including your policy, medical records, and other documents you have on hand.

Long-term disability policies often contain the most restrictive provisions and language that can make your claim more challenging to file. These claims are often the most difficult to get your long-term disability insurance company to honor and are most easily compromised by not understanding the policy, procedures, and the law. These policies usually contain specific language and deadlines as mandated by the Employee Retirement Income Security Act (ERISA). It is important to review your disabling condition in light of the definition of disability in your long-term disability policy. At Seltzer & Associates, we can assist you in this review.

In addition to reviewing your potential claim, we will begin the process of explaining to you what you can expect to encounter as you engage your disability insurance company in the claim process. We will help you make the most informed and effective decision as to how to proceed in filing your claim for your long-term disability benefits.

Let a Philadelphia ERISA disability attorney at Seltzer & Associates assist you in this process to protect your rights under your policy. Contact our firm before it is too late.