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Common reasons ERISA disability claims are denied

Short-term or long-term disability insurance through your employer is not the safety net you think it is. Employees who actually file ERISA disability claims are regularly turned down, often with little explanation and little recourse.

Why was your claim denied? It may have to do with the fine print of the policy or a mistake in filling out the paperwork. Whatever the reason, it is possible to appeal an adverse decision. New rules that are favorable to claimants may help to level the playing field, but you will still likely need an attorney who understands how to fight insurers of ERISA plans.

It doesn’t take much for ERISA claims to be rejected

Claims that would likely be approved under Security Security disability or a private disability policy are frequently rejected under ERISA plans. Here are some of the common justifications for denying long-term disability claims:

  • Lack of medical evidence of a disabling condition
  • Errors or incomplete information in the claim
  • Missed deadlines
  • Pre-existing medical conditions
  • Self-reported (not medically documented) symptoms
  • Inappropriate treatment (not authorized or out of protocol)
  • Contradicting evidence obtained from social media or private investigators
  • Employability in some occupation
  • Specific policy exclusions

The uphill battle for ERISA disability benefits

Employer-sponsored disability plans are governed by the Employee Retirement Income Security Act (ERISA). The rules are highly favorable to the insurance companies. They can get away with wishy-washy reasons for denial. They are immune to lawsuits unless you can meet the high burden of proving that their decision was “arbitrary and capricious.” There is an appeals process, but it is very complex and stacked against the claimant.

In mounting an appeal, we would press for as much information as possible about why the claim was denied. Our attorneys are hopeful that new rules governing ERISA claims and appeals will make it harder for insurers to deny valid claims in the first place, and easier for claimants to challenge unfair denials.

Under new rules, insurers must be clear about the reasons

The rules were implemented by the U.S. Department of Labor. They apply to all ERISA disability claims filed on or after Jan. 1, 2018. Perhaps the most important change is that insurers must provide a “reasoned explanation” when denying claims. They must disclose a specific reason other than “did not meet our criteria.” They must detail why they disagree with your doctors or third parties who determine you are disabled. They must specify the internal rules and procedures by which they reached their decision. And they must provide you with relevant documentation on request.

Make no mistake, ERISA appeals are still very difficult even with an experienced attorney on your side. ERISA disability policies are drafted in such a way that insurers have several avenues to reject claims, and there is very little due process – not even a hearing to present your case. But the transparency and accountability in the new rules will help to level the playing field in your favor if you need to file or appeal an ERISA disability claim.

 

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