Our attorneys assist clients in getting disability benefits under employer sponsored disability plans.
If a serious medical condition causes you to be unable to work, even temporarily, you may be entitled to disability benefits from your employer sponsored disability plan. Be careful: The process of applying for benefits has many pitfalls.
If you submitted a claim for disability benefits from your employer sponsored disability plan and your claim was denied, you should receive a letter from the insurance company informing you that you have the right to appeal the decision within 180 days.
That letter may have failed to tell you other important information, such as how to “perfect” your appeal and successfully reverse a claim denial. If the letter fails to provide this information, this is a violation of a federal law known as Employee Retirement Income and Security Act (ERISA) and U.S. Department of Labor regulations that insurance companies are required to follow.
Your Employer Sponsored Disability Claim File
The insurance company’s letter may not inform you that you have the right to a copy of all the documents in your claim file. You need to have these documents to be sure that the insurance company has all of your medical records and also to determine whether any important records are missing or were ignored.
It is important to see if your file contains a report from a medical professional who reviewed your records (but did not understand your medical issue) so that you can have your own doctor respond to that report. You also should look at how the insurance company determined what your occupational duties are to see if the job description in your file accurately describes the demands of your job.
You have a right to review all of the employer sponsored disability benefit plan documents. The insurer may have disregarded the language of your employer’s plan – which governs your right to benefits – and applied the terms of its own insurance policy instead. You may need to request the plan documents from your employer, but the insurance company will not tell you so.
Even if the insurance company denial letter seems to inform you of your rights, the reasons why they denied your claim may be questionable. The letter may show that your records were reviewed by an in-house physician. Reviews by in-house physicians are problematic for several reasons:
(1) The review may be biased. It is in the insurance company’s financial interest to deny your claim. Insurance company employees who review your claim may be pressured to “cherry pick” your records for statements to show that the claim should be denied, and to downplay records that would support your disability claim.
(2) A “paper review” of your claim file, without a physical examination, may ignore some of your symptoms, such as pain, limited mobility, or impairment of your cognitive (thinking) abilities.
(3) The reviewer assigned to your file may not have the appropriate training and knowledge to interpret your records or understand the side effects of your prescription medications.
(4) The insurance company’s reviewer may say that your condition is due to “subjective” symptoms, and ignore your doctor’s clinical examination findings, or discount your condition because you did not have objective diagnostic testing, even though there may not even be tests for your condition.
The insurance company may have undertaken surveillance or searched social media sites to try to show that you are capable of the activities of daily living. While such tactics are not illegal, insurance companies often misstate what a video surveillance shows. For example, if you leave your house for a short period of time to go to a medical appointment or to care for yourself, it does not mean that you have the ability to work full time. You have a right to review any surveillance and determine whether the denial letter accurately describes it.
You may have called the insurance company to explain why you believe that your claim should not have been denied. If you were told by the insurance company that your claim will be straightened out on appeal and you do not need to send any additional information, DO NOT BELIEVE IT. If you do not make sure that all the information necessary to support your claim is in your claim file, and your appeal is denied, it will be difficult to add more information if you need to file a lawsuit in order to receive your employer sponsored disability benefits.