Our law firm represents clients that have either group or individual disability policies. Most group disability policies (also known as ERISA policies) are governed by a very complex federal statute called the Employees Retirement Income Securities Act, (“ERISA”). An individual usually has a group disability policy, if they received the disability policy as an employee benefit from an employer, or in some instance purchased the policy from a trade association that offers the discounted disability income policy to it’s members. .

ERISA /Group Policies Are Different From
Private Policies In Several Significant Ways.

First, with an individual private policy if your insurance carrier denies your claim, you usually have the right to file suit and begin to gather your evidence. However, with most group policies you must submit a written appeal, within a specified time period, directly to the insurance company prior to filing suit. This requires gathering all of the evidence that would be helpful at trial and submitting it with your formal appeal. In order to present our client’s case in a light most favorable to the insured, we work very closely with our clients and their treating physicians, to insure that the appeals are submitted with an overwhelming amount of information and detail. A well document appeal is essential in order to have a chance of being successful at an ERISA non-jury trial.

Second, unlike a individual private policy claim, an ERISA disability insurance case is heard in federal court without a jury. There is usually no testimony by the insured, experts, or physicians. The evidence is limited to the documentation provided during the application stage, documents contained in the Appeal, and previously gathered information by the insurance carrier. We prepare all of our appeals in anticipation that the case may go trial in the event an Appeal is denied.

Third, unlike a individual private claim, at trial you are not attempting to prove only that you are in fact disabled. The test is much more stringent. The insured has the burden of showing that given all the evidence submitted by the insured and gathered by the insurance company, there is no reasonable way that the insurance company could have determined that the insured is not disabled.

ERISA provides extremely strict guidelines and deadlines for disabled claimants seeking disability insurance benefits under their group policies. If sufficient information is not submitted within these timelines, a claimant may be forever barred from introducing the documentation to prove their disability. Frustrating as it may seem, the disability carrier will not tell you what is necessary to perfect your claim. Moreover, group disability income policies are drafted with ambiguous and confusing contractual terms. These ambiguities provide insurance companies with multiple reasons for delaying and denying disability income benefits. Furthermore, most policies provide the insurance company with full discretion in deciding whether sufficient information has been provided by claimants prior to approving a claim. Given the complexity of the legal issues involved and the tendency of insurance companies to vigorously defend claim denials, evaluation of any potential legal claim on behalf of an insured should be handled by a law firm experienced in ERISA insurance claims.

We are available to provide you with a free consultation and review of your disability policy. Please keep in mind that there are time deadlines with ERISA claims and we must have sufficient time to evaluate your claim and take the appropriate legal actions on your behalf.