There are two types of people in the world—the “it’s never going to happen to me” type and the “be prepared for anything” type. If you fall into the latter category, you are probably a firm believer in buying insurance. While almost everyone would agree that health insurance is vital—and we know that car insurance and homeowner’s insurance are required—be-prepared people also opt into other kinds of insurance, such as life insurance, renters’ policies, and long-term disability (LTD) plans.
Sometimes, these bonus policies are offered as part of an employee benefits package which you might opt into, but other times, individuals purchase a policy on their own. With LTD plans, how you got the insurance will be important if you file a claim that is denied and want to appeal. We explain why it matters.
Employer-Sponsored LTD Policies
If your employer offers an LTD policy as a benefit, whether you must pay part of the premium or not, that policy is governed by a federal law called the Employee Retirement Income Security Act (ERISA). Enacted in 1974 to protect employee pensions and retirement savings, it has been expanded over the years to cover most non-governmental employee benefit plans, including life insurance, sick leave, healthcare, and disability insurance. In terms of LTD policies, ERISA guarantees the right to appeal a denial but also makes it incredibly complicated. There are strict deadlines, tight restrictions, and no second chances. If your employer-sponsored LTD claim is denied, you will want to find an attorney who takes ERISA claims. Because this is such a picky and specific area of the law, not every lawyer who handles disability denials takes ERISA claims. Monast Law Office does.
Individual LTD Policies
If you are a “be prepared” person who bought a long-term disability policy directly from an insurance company, you would not need an ERISA attorney if your claim for benefits is denied. Appeals of individual LTD policy denials are governed by the laws of the state in which you are insured. This is a different process that requires the knowledge of a lawyer who takes these cases. Be sure you know what type of policy you have so you can communicate with the appropriate legal professional if your claim is denied.
When Can You Appeal a Denial?
Even if your LTD policy is subject to federal ERISA laws or state law, you can only successfully appeal a denial if you have cause. The insurance company must have made a procedural error or acted in an unreasonable manner. ERISA allows certain specific causes, and each state might allow some causes and not others, but, generally, these actions are valid reasons for appeal:
- Breach of contract
- Breach of good faith
- Breach of fiduciary duty
When your claim is denied, the first thing you should do is talk to a lawyer who handles denials of the policy you have to see if you have cause for an appeal.
Other Types of Disability Claims
Long-term disability income policies are not the only coverage you might have when you cannot work due to an illness or injury. Because the word “disability” is used loosely by people to refer to any payment they get when unfit to work, it can be confusing. Many people have access to several types of disability plans, including:
- Workers’ compensation. Workers’ comp covers workers injured on the job or develop an occupational illness due to workplace exposure.
- Social Security Disability Insurance (SSDI). For people with a qualifying work history, SSDI kicks in for certain approved disabling conditions.
- Supplemental Security Income (SSI). For low-income individuals, regardless of work history, SSI is available to individuals wover the age of 65, blind, or have a disability.
- Veterans disability. The VA offers payments to veterans who got sick or injured while serving in the military or whose service made an existing condition worse.
If your claim for these types of disability has been denied, seek advice from a lawyer who accepts those specific claims.
Talk to Monast Law Office About Your ERISA LTD Appeal
For over 30 years, I've dedicated my practice to providing injured workers with the guidance and representation they need to get the disability benefits they deserve. If your employer-sponsored LTD claim was denied, call our office in Columbus at 614-515-2595 to see if we can help you! You can also request a free download of my book on LTD claim denials.