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
Showing posts with label Unum. Show all posts
Showing posts with label Unum. Show all posts
Tuesday, April 10, 2007
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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