What Will The Claim Administrator Do To Investigate The Claim?

The insurance carrier can obtain your medical records, conduct a phone or an in-person interview with you, and conduct surveillance of your activities, both online and in person. Social media is one of the biggest ways they can conduct an investigation without even leaving their office. They can also send you to their doctor for a medical exam.

What Can I Do If My Claim Is Denied?

In an ERISA case of a group disability policy, you will have 180 days to appeal a long-term disability denial. This is where you must submit all the evidence in support of your disability because you must address all the points raised by the insurance company in the denial. You may have to obtain testing or a vocational evaluation to provide the information that is missing. You may need to submit literature or research, to educate the decision maker about your unique situation. You’re creating a record that will educate the judge, should the insurance company deny your claim.

The insurance carrier will then have 45 days to decide the appeal. They can extend the deadline for another 45 days, if they need extra time to decide the appeal. If you fail to appeal, you will forfeit your right to sue the insurance company. In an individual disability claim, if they deny your claim, you can sue them in state court.

Why Does It Matter If The Benefits Are Governed By ERISA Or Not?

In an ERISA case, we’re talking about federal law; with an individual policy case, it is state law. The claim procedures are different and the remedy is different. Under ERISA, you have to appeal within 180 days and you have to appeal to the insurance company who denied the claim. They have the right to decide whether you’re disabled or not. When it gets to a hearing, the judge decides the case based on an abuse of discretion standard rather than a de novo standard. The remedy, under an ERISA claim, is different from that under state law.

What Legal Remedies Are Available Under Florida Law?

Under Florida law, you can seek damages for breach of contract. An insurance policy is a contract that you have with the insurance company to pay you, if you’re disabled. If they breach that, you can sue under breach of contract for your loss of benefits. You may also be able to recover compensatory damages and if the insurance company acted in bad faith, you can get punitive damages. Your insurance company might also have to pay your attorney’s fees and costs, under Florida state law.

What Are The Legal Remedies Under ERISA?

Unfortunately, under ERISA, your recovery is limited to what you were entitled to, had the insurance company not denied your claim. That would be a portion of your lost wage and maybe legal fees and interest, but that is at the discretion of the court. Under ERISA, there are no punitive damages or payments for acting in bad faith. Therefore, there is no real incentive for the insurance company to do the right thing.

For more information on Investigating A Disability Claim In Florida, a free initial consultation is your next best step. Get the information and legal answers you are seeking by calling (352) 577-7746 today.