ERISA Compliance Issues
If you have long term disability insurance through your employer, then the plan is likely subject to compliance with ERISA. ERISA, or the Employment Retirement Income Security Act of 1974, is a federal law that sets standards for many employer-provided benefits. Your long-term disability insurance plan may be subject to an array of ERISA compliance issues, and you likely have questions. Learn more from CJ Henry Law Firm, PLLC today.
Is My Policy Covered by ERISA?
It’s important to determine whether or not your long term disability policy is governed by ERISA. While most employer sponsored plans are covered, others are not. If you work for a government entity (federal, state, or local), Indian tribal entities, or a church, your plan is not likely to be covered by ERISA.
What Does ERISA Cover?
Many of the benefits plans offered by employers fall under ERISA, including:
- Health insurance plans
- Accidental injury and illness plans
- Disability plans
- Unemployment benefits
- Vacation benefits
- Child care center plans
- Scholarship funds
- Prepaid legal services
- Holiday or severance pay
- Retirement plans
- Apprenticeship and training programs
CJ Henry Law Firm, PLLC has experience with an array of ERISA plans, in particular long-term disability policies.
Things You Should Know About ERISA Compliant Plans
The details of your long term disability policy will determine the standards required to approve or deny your claim. Some common issues that come up include:
- Your policy’s definition of “disability” – Some policies define disability as being unable to perform the duties of your own job, and others define it as being unable to perform the duties of any job. Some policies switch from an “own occupation” definition to an “any occupation” definition over time.
- Your policy may have an “elimination period” – It is common that you will have to wait between 90 and 180 days between when you become disabled and when you are eligible for long-term disability. Your employer may offer short-term disability to fill this gap.
- You must provide a plethora of medical evidence – You must prove you have been diagnosed with a condition and the severity of that condition meets disability standards. This usually requires a lot of medical records and doctors’ statements.
- You will only receive a portion of your paycheck – Long-term disability insurance plans typically only provide 60% or a similar number of your normal pay. They are not dollar for dollar replacements of pre-injury income.
Common ERISA Compliance Issues
ERISA is a constantly changing law. Thus, your disability insurance policy must comply with the law as it changes. Rules and processes for adjudication, denials, and appeals are modified on a regular basis. It is the responsibility of the long term insurance company to know about these changes and comply. However, they may violate ERISA if no one calls them on their illegal practices.
Some updated ERISA practices include the following:
- Your long term disability insurance company must provide a full explanation of why your claim is denied. If their opinion disagrees with the doctor’s opinion, they must address that disagreement.
- The denial notice that you are sent must include internal rules, guidelines, protocols, and standards that the plan used to deny the claim. It may also state that none exist.
- The long-term disability insurance company must notify you of your right to access and obtain copies of any claim documents and records.
- You must be given an opportunity to review and respond to new and additional evidence before a final appeal decision is made in your claim.
What to Do If Your Claim Is Denied
Many long-term disability claims are denied initially. Your first step should be to seek out a knowledgeable attorney who can evaluate your denial documents and help you make a decision about your next best steps.
If you need to obtain additional medical evidence for the LTD insurance company, then you may need a new doctor or a specialist. You should continue seeing all of your providers so that your medical records are ongoing and show the severity of your condition. If you stop going to the doctor, the LTD company may assume you are well or no longer need to be considered disabled.
Call CJ Henry Law Firm, PLLC Today
We have worked with thousands of clients facing ERISA compliance issues in LTD claims. Call us today.