All about Disability Claims

Most group or employer-provided insurance policies are governed by the Employee Retirement Income Security Act of 1974 (“ERISA”). ERISA provides extremely strict deadlines and guidelines. If a claimant does not adhere to these strict guidelines and deadlines, the result can be disastrous for him or her. Unfortunately, while insurance carriers are not free to ignore their obligations under ERISA, often claimants are unaware of their rights and violations go unchallenged. If your group insurance policy is governed by ERISA, you must exhaust your administrative remedies prior to filing a lawsuit.

While appealing to the insurance company that already denied your claim may seem like a fruitless effort, ERISA appeals should never be taken lightly. This is because, in most circumstances, the only information that you are able to present in a lawsuit is the information provided to the insurance company during the application and appeals process. Accordingly, if your claim is denied, you are not just submitting an administrative appeal, but preparing your case for trial.

Most insurance companies never explain this to claimants and unfortunately, many ERISA-governed claims are lost because of it. Most claimants would never think of preparing to face their insurance company at trial without the help of an experienced attorney. However, by preparing their own administrative appeal, they are doing just that. If you fail to present all of the information you would normally present at trial in your appeal, you will likely never have an opportunity to do so.

It is important to have an attorney with ERISA experience.
he attorneys at Law Offices of Nicholas Taldone prepare our client’s appeal as if we are preparing for a lawsuit. We expend the time, resources, and knowledge of the law necessary to prepare each of our client’s appeals. This often includes:

Testimony from our clients, treating physicians, co-workers, employers and family members
Expert medical opinions
Independent Medical Examination reports that we obtain for our clients
Vocational rehabilitation reports and other expert reports
A thorough examination of our client’s unique situation and the law that applies to their claim

Moreover, ERISA-governed insurance benefit cases are not submitted to a jury. Instead, a single judge makes a determination as to eligibility for benefits. This is based on the administrative record (the information gathered during the application and appeals process) and the complex federal law, ERISA. There are many situations in which additional information may come into the lawsuit, but such matters are typically fiercely fought by the insurance companies and involve highly complex legal strategies.

Here are some legislative sites you may find of interest. You should also visit www.dol.gov/general/topic/healthplans, which is the U.S. Department of Labor’s website, for more information.