You receive a letter from your insurance company advising you that your disability claim is denied or terminated. After the initial shock wears off, what steps can you take to obtain your disability benefits? What you should NOT do is immediately write back, telling your insurer they have made a mistake, and ask them to reconsider your claim. You will eventually want to do so; however, there are several steps you need to take first.
If your disability policy is part of an employee benefit plan then it is probably governed by Federal Law known as the Employee Retirement Income Security Act (ERISA). Under ERISA, the insurer/plan must give you 180 days following a termination or denial of benefits in which to request an administrative appeal or review of your claim. However, most plans give you only one shot at an appeal. Thus, you must use this opportunity wisely.
The first thing you should do is request from the insurer, a copy of their entire file on your claim. They are obligated to provide it to you, without cost, within 30 days of a written request. Once you receive this file you should go through and organize it in some fashion, i.e, putting all the medical records together segregated by provider and in chronological order. Once you have organized the file it will be easier for you to see what is missing from the records. If they had your file reviewed by their own medical or vocational consultants, you will see their reports and have a better understanding of why they denied or terminated your claim.
You should also obtain, if you do not already have it, a copy of the plan or disability policy that sets forth all your rights and obligations. You should be able to obtain the policy from the administrator of the plan who is typically the employer. However, if there is a claims administrator, then they will most likely be able to send that document to you.
It is at this point I would strongly suggest you contact an attorney. An initial conference with an attorney should not cost you anything. However, make sure the attorney is experienced in handling ERISA benefit claims. The law applicable to these claims is unique and technical. If you have done your homework and have the claim file, the policy and your letter of denial, you should be able to answer many of the questions the attorney will have to help you evaluate your claim. You are most likely emotionally attached to your claim and getting input from an experienced attorney can often be enlightening. Remember, the fact that you are disabled does not guarantee that you will receive benefits. It does not matter how many times you tell the insurer that you are in pain and cannot work. What is important is the presentation of evidence that sets out your physical limitations associated with your illness or injury and how those limitations preclude you from performing the duties of a job.
If you want more information about ERISA or wish to talk to or email an expert about your claim, visit our website at www.StennettCasino.com.
Showing posts with label ERISA. Show all posts
Showing posts with label ERISA. Show all posts
Wednesday, July 8, 2009
Tuesday, April 10, 2007
What Is ERISA
In 1974, Congress passed a law that regulates your employee benefits. Known as ERISA (the Employment Retirement Income Security Act) this law covers your retirement, disability, health, life and other employment-related benefits. It details the responsibilities of your employer regarding your employee benefit plan, and it outlines the steps you can take if you believe your rights are being violated. ERISA is a Federal law. State laws will not apply since they are preempted by ERISA. However, if you are employed by a governmental entity then ERISA does not govern your employment benefits. (State laws of insurance "bad faith" may then apply).
ERISA has a two-step claims procedure. You first must file a claim, with proof that you qualify for benefits, with the Plan's Administrator. Typically, your employer will provide you with the claim forms. Most disability, life and health Plans are underwritten by an insurance company. (Unum, Prudential, Met Life, Hartford, etc.). In these cases your claim will be reviewed by the insurance company (referred to as the Claim Administrator). Both the Plan Administrator (employer) and the Claim Administrator (insurer) have a fiduciary responsibility "to act solely in the interest of the [Plan] participants and beneficiaries." However it may be fatal to your claim to assume that the Administrator will assist you in proving your claim. You are responsible for proving your own claim.
If the Plan denies your claim, you have the right to an administrative appeal. The Claim Administrator will review your claim a second time. You have a right to obtain a copy of the administrator's file. Get it! This file will tell you what they have reviewed and what their own internal consultants (medical reviewers, vocational analysts, surveillance video) are saying about your claim.
The appeal process is a critical point in your claim. A time when you should at least talk to an attorney with expertise in ERISA. The reason being that if your appeal is also denied your remaining remedy is to file suit in Federal court. ERISA limits your rights in court. You have no right to a jury and virtually no right to perform discovery. Thus all of your discovery needs to be done during the administrative appeal process. When the judge reviews your case he will be limited to reviewing what is in the administrative file. You can not hold back the "good stuff" for trial. If it was not presented during the administrative review then the judge will not consider it. There are many things that can be done to bolster your claim. See the article, "Excuses...", for ideas.
There are usually deadlines both for submitting your claim and filing your appeal, although it may be possible to obtain a deadline extension. Make sure you comply with these deadlines.
It is highly recommended in these technical ERISA cases that you speak to an ERISA attorney early in your case. If you retain an attorney make sure he/she has specialized knowledge in ERISA and insurance company practices. An attorney can help you to fully document your claim by gathering all the documents, seek out additional experts or specialists, interview witnesses and compile legal and factual support for your claim. If you want to obtain more information about ERISA or wish to email or talk to an expert about your claim visit our web site at stennettcasino.com
ERISA has a two-step claims procedure. You first must file a claim, with proof that you qualify for benefits, with the Plan's Administrator. Typically, your employer will provide you with the claim forms. Most disability, life and health Plans are underwritten by an insurance company. (Unum, Prudential, Met Life, Hartford, etc.). In these cases your claim will be reviewed by the insurance company (referred to as the Claim Administrator). Both the Plan Administrator (employer) and the Claim Administrator (insurer) have a fiduciary responsibility "to act solely in the interest of the [Plan] participants and beneficiaries." However it may be fatal to your claim to assume that the Administrator will assist you in proving your claim. You are responsible for proving your own claim.
If the Plan denies your claim, you have the right to an administrative appeal. The Claim Administrator will review your claim a second time. You have a right to obtain a copy of the administrator's file. Get it! This file will tell you what they have reviewed and what their own internal consultants (medical reviewers, vocational analysts, surveillance video) are saying about your claim.
The appeal process is a critical point in your claim. A time when you should at least talk to an attorney with expertise in ERISA. The reason being that if your appeal is also denied your remaining remedy is to file suit in Federal court. ERISA limits your rights in court. You have no right to a jury and virtually no right to perform discovery. Thus all of your discovery needs to be done during the administrative appeal process. When the judge reviews your case he will be limited to reviewing what is in the administrative file. You can not hold back the "good stuff" for trial. If it was not presented during the administrative review then the judge will not consider it. There are many things that can be done to bolster your claim. See the article, "Excuses...", for ideas.
There are usually deadlines both for submitting your claim and filing your appeal, although it may be possible to obtain a deadline extension. Make sure you comply with these deadlines.
It is highly recommended in these technical ERISA cases that you speak to an ERISA attorney early in your case. If you retain an attorney make sure he/she has specialized knowledge in ERISA and insurance company practices. An attorney can help you to fully document your claim by gathering all the documents, seek out additional experts or specialists, interview witnesses and compile legal and factual support for your claim. If you want to obtain more information about ERISA or wish to email or talk to an expert about your claim visit our web site at stennettcasino.com
Sunday, April 8, 2007
Excuses Used By Insurance to Deny Disability Claims
Every denial of disability benefits includes the language "your medical records do not support a claim for disability as defined in the Plan." What does that mean and what can you do about it? Plenty. First you must understand that there are two issues presented in that often used excuse to deny benefits. The definition of disability in the Plan and your medical records. (The issues are the same in an ERISA Plan, Governmental Plan and Individual Plan).
How is "disability" defined in your Plan? You must read it to know. For example is it "the inability to perform the material duties of your own occupation" or "the inability to perform the material duties of any occupation"? If it is "your own occupation" then get a copy of the job description from your employer. If it is incorrect or incomplete then tell the Plan. Once the job duties are defined then determine how your illness/injury prevents you from performing those duties. If your job requires you to sit at a computer terminal 7 hours a day and you can only sit 2 hours a day then make sure your medical records reflect that fact.
How do you control what is in your medical records? The doctor performs the examination orders the diagnostic tests and makes the diagnosis. But the diagnosis alone does not necessarily define what your limitations are in a work setting. One person with a bulging disc may not even know he has a problem while another with the same diagnosis may be totally disabled. Each person is unique and each person reacts differently. To determine how an injury/illness affects you the doctor has to rely on what you tell him.
Do not just tell the doctor that your back hurts and you cannot work. Tell the doctor that your job requires you to sit at a computer 7 hours a day and you can only sit for 30 minutes before the pain gets so bad that you need to lay down for 20 minutes to lessen the pain. Every time you see the doctor and he asks "how are you doing" give him something interesting to write in the medical record so that it supports your inability to perform the material duties of your occupation. Tell him that you really want to return to work but at work you have to get on your knees all the time and you cannot do that yet. Tell him it bothers you that you cannot invite friends over for dinner because you cannot sit at the dinner table long enough to be social. Tell the doctor how your injury/illness affects your life. Let the medical record support your disability
There are many other methods to fully document your disability as well as many other excuses insurers like Unum, Prudential, Hartford, Met Life, Reliance Standard and others use to deny disability claims. Please visit our insurance disability web site at StennettCasino.com for additional information or to contact a disability attorney who can answer your questions whether you are dealing with an ERISA disability plan or a private disability plan.
How is "disability" defined in your Plan? You must read it to know. For example is it "the inability to perform the material duties of your own occupation" or "the inability to perform the material duties of any occupation"? If it is "your own occupation" then get a copy of the job description from your employer. If it is incorrect or incomplete then tell the Plan. Once the job duties are defined then determine how your illness/injury prevents you from performing those duties. If your job requires you to sit at a computer terminal 7 hours a day and you can only sit 2 hours a day then make sure your medical records reflect that fact.
How do you control what is in your medical records? The doctor performs the examination orders the diagnostic tests and makes the diagnosis. But the diagnosis alone does not necessarily define what your limitations are in a work setting. One person with a bulging disc may not even know he has a problem while another with the same diagnosis may be totally disabled. Each person is unique and each person reacts differently. To determine how an injury/illness affects you the doctor has to rely on what you tell him.
Do not just tell the doctor that your back hurts and you cannot work. Tell the doctor that your job requires you to sit at a computer 7 hours a day and you can only sit for 30 minutes before the pain gets so bad that you need to lay down for 20 minutes to lessen the pain. Every time you see the doctor and he asks "how are you doing" give him something interesting to write in the medical record so that it supports your inability to perform the material duties of your occupation. Tell him that you really want to return to work but at work you have to get on your knees all the time and you cannot do that yet. Tell him it bothers you that you cannot invite friends over for dinner because you cannot sit at the dinner table long enough to be social. Tell the doctor how your injury/illness affects your life. Let the medical record support your disability
There are many other methods to fully document your disability as well as many other excuses insurers like Unum, Prudential, Hartford, Met Life, Reliance Standard and others use to deny disability claims. Please visit our insurance disability web site at StennettCasino.com for additional information or to contact a disability attorney who can answer your questions whether you are dealing with an ERISA disability plan or a private disability plan.
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