Is my disability insurance policy subject to or governed by ERISA?

It is rare that any disability insurance claimant has ever heard of ERISA until it comes time to file a disability claim. ERISA is a federal law that was intended to offer affordable employee benefits and protect employees. ERISA accomplished the goal of affordable employee benefits, but unfortunately the ERISA regulations have been construed by the courts in such a way that ERISA favors insurance companies. In every disability claim, we try to prove that a claim is not governed by ERISA so that our clients can have the best chance of collecting benefits. To learn more about why ERISA is an unfair law, please watch this video.

Individual v. Group Disability Insurance Policies

Generally speaking there are two types of disability insurance policies: “Group” and “Individual.” A Group policy is a policy provided by an Employer which is usually subject to ERISA, and an Individual policy is purchased independent of your employer usually through an insurance agent and is not subject to ERISA. More than 85% of the people with disability coverage have a group policy governed by ERISA.

Five Requirements For A Disability Policy To Fall Under ERISA

So is your policy subject to ERISA? Like many things in the world of disability insurance policies, the answer is not always clear cut with respect to “Group” disability insurance policies. Federal courts throughout the country have stated that there are five requirements in order for a group disability policy to fall under ERISA:

  1. A “plan, fund, or program”
  2. established or maintained
  3. by an employer or employee organization, or both
  4. for the purpose of providing medical, surgical, hospital care, sickness, accident, disability, death, unemployment or vacation benefits
  5. to participants or their beneficiaries.

In reviewing this list it becomes somewhat clearer that an ERISA governed disability policy is one that is sponsored by an employer. Generally, these policies are part of a benefits package, and may or may not require a small portion of the premium be paid by the employee while the remainder is paid by the employer. The above analysis is further scrutinized to determine the true nature of employer relationship with the policy and the way in which the policy is offered.

What are “Safe Harbor” Regulations and How do They Apply to Disability Insurance Policies

The Department of Labor has issued what are known as “safe harbor” regulations providing “that group insurance offered to workers through their place of employment will not be deemed an ERISA plan if the insurance program satisfies certain enumerated criteria.” So how does one determine if a policy falls within the “safer harbor” regulation? The ERISA statute provides four criteria for a policy to be considered not governed by ERISA under the “safe harbor” regulation. Failure to meet all four criteria means the Group policy is subject to ERISA. The four factors are:

  1. No contributions are made be an employer or employee organization;
  2. Participation in the program is completely voluntary for employees or members;
  3. The sole functions of the employer or employee organization with respect to the program are, without endorsing the program, to permit the insurer to publicize the program to employees or members, to collect premiums through payroll deductions or dues checkoffs and to remit them to the insurer; and
  4. The employer or employee organization receives no consideration in the form of cash or otherwise in connection with the program, other than reasonable compensation, excluding any profit, for administrative services actually rendered in connection with payroll deductions or dues checkoff.

For example, most short term disability plans provided through Aflac fall into all 4 criteria and therefore are not governed by ERISA.. You may have experienced a situation where your HR advises you that an Aflac representative will be in the office to discuss signing up for coverage; that if you sign up for it you will be solely responsible for paying the premiums; that it is completely voluntary and you don’t need to sign up for the coverage; that if you do sign up for it, the premiums can be paid out of your pay check; and that the employer does not stand to gain financially from the arrangement.

Is the Analysis Over? Not yet!

If only this was the final portion of the analysis as to the whether ERISA would apply to your policy it would seem simple enough”¦ well maybe. The above noted factors have been further scrutinized by Courts to determine if the disability policy at issue in litigation is governed by ERISA or by a state law action. Courts point to a seven prong analysis to try to make this determination:

  1. The employer’s representations in internally distributed documents;
  2. The employer’s oral representations;
  3. The employer’s establishment of a fund to pay benefits;
  4. Actual payment of benefits;
  5. The employer’s deliberate failure to correct known perceptions of a plan’s existence;
  6. The reasonable understanding of the employees; and
  7. The employer’s intent.

These last seven factors result in even more uncertainty as to the ultimate question of whether a disability policy from your employer really is an ERISA governed plan. Unfortunately there is no finite, cookie-cutter answer, and it is often necessary to gather numerous documents from your employer in order to obtain a final answer. In most cases that result in litigation, the necessary documents can be obtained during the litigation of the claim.

At the end of the day, the claimant still has a good chance to win their case, but the odds are much better if the claim is not governed by ERISA. If you have questions regarding your disability insurance policy, the disability attorneys at Attorneys Dell and Schaefer, will always provide you with a free initial consultation.

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FAQ

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Dell & Schaefer Client Reviews   *****

Bert M., DDS

I was referred to Dell & Schaefer thru a network group of top clinicians who gave them a very positive recommendation. I was not disappointed. Dell & Schaefer’s organisation, confidence and direction proved invaluable during a very frustrating and emotional period. We were fortunate to get them onboard at onset of my medical problems, and their help was pivotal as the demands of my illness and the claims procedure became very challenging. I can’t say enough positive things about Stephen Jessup, Greg Dell and the many valuable members of their team. They possess unique knowledge and experience critical for success in this field, and demonstrate a sincere commitment to success for their client. These are highly skilled professionals who provided outstanding guidance and personal support through the processing and management of my professional disability insurance claim.

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