Claims

Is There a Conflict of Interest If the Party Paying Benefits Is The Same Party Who Decides Eligibility? On Thursday, the Supreme Court answered this question with a resounding YES! The Court found, what every plaintiff ERISA practitioner already knew, that when a company determines eligibility and pay benefits out of its own pocket there is an inherent conflict of interest. Recognizing this conflict of interest, the Court went on to state that a reviewing court should consider an insurance company's conflict of interest when reviewing the denial of an employee's health or disability benefits claim. While the court did not provide much guidance on how much weight should be given to the conflict, it provides that the reviewing court…Read More

Did you know that in ERISA disability cases there are no real trials? That’s right, NO TRIAL. Once the insurance company denies your disability claim and your appeal is over, you get a chance to file a lawsuit. However, this suit isn’t tried before a jury of your peers. You cannot bring in witnesses to testify about how disabled you are. You cannot tell the Judge how your illness or injury prevents you from working. Not even your doctor can come in and testify on your behalf. When you file a lawsuit in an ERISA disability case, a Judge will decide your case. The only evidence he will review is what is already in the claim file when the insurance…Read More

I frequently get calls from long term disability claimants wanting to know if their disability insurance company can get all their social security back benefits. Often they recall some discussion with the insurance carrier about coordination of benefits, but fail to fully appreciate what it meant. In a nutshell, most group disability policies have a provision that allows the insurance company to offset other income benefits. This means they take credit for the income the disabled individual received from other sources of income such as social security disability, pension, retirement, worker’s compensation, or even settlement from an accident that resulted in the disability benefits. In some cases they can take credit for the social security income that their children receive…Read More

Unfortunately, Congress did not offer this protection to individuals injured by their group disability insurance company. The insurance company can wrongly deny your claim; make you retain and pay a lawyer and if they lose in court, their only obligation is to pay you what they should have paid you if they didn’t wrongly deny your claim. That’s outrageous! My best advice is to do your homework. Know the reputation of the insurance company before you purchase your disability policy. If you already purchased a policy, become familiar with the terms before you file a claim. Get an experienced ERISA lawyer before filing your claim. They can help you understand what you need to do to establish entitlement to benefits…Read More

Sometimes individuals are unaware of how their conduct may affect the entitlement to benefits that they have secured for their loved ones. I continue to encourage everyone with a group disability policy or group life insurance policy to get a copy and read it. Know what is covered and what is excluded. Recently, I was asked to evaluate the case of a young man who died as a result of participating in a street race. The widow’s attempt to collect the life insurance proceeds was met with denial by the life insurance carrier on the basis that he was engaging in a criminal offense (2nd degree misdemeanor in the state of Florida). The policy excluded coverage for loss caused in…Read More