Riverside, North San Diego, Orange Co. (949)-645-9366

Long Term Disability (LTD) and ERISA Benefits

 
LTD and ERISA Lawyers: Riverside, North San Diego & Orange Counties
 
LTD Benefits: Key Misconceptions
 
1.  Your LTD insurance carrier will protect your interests regarding your benefits and help get you approved.
2.  Your HR department is on your side and will help ensure you get the deserved benefits per the policy.
3.  You don't need a lawyer: your medical record will persuade the LTD carrier to approve the claim.
 
LTD and "ERISA" OVERVIEW
 
ERISA” stands for the Employee Retirement Income Security Act of 1974. Many employer- based long-term disability plans, which may be provided as a “fringe benefit” by employers to employees, are governed by ERISA federal law. You may be covered by an ERISA plan. It is important to check right at the outset of your disability application, because ERISA law is complicated, and you are well advised to seek the help of a knowledgeable attorney. Don't try to do it yourself.
 
Definition of “Long-Term Disability.”
 
The first thing to look at, when filling a claim for disability benefits, is exactly how your Plan defines “disability.” Definitions vary from plan to plan, but there are some common features. For example, many plans first provide for short-term disability (STD) benefits for a period, and then if you complete the short-term period, you become eligible for long-term disability (LTD)  benefits.
 
Key concept #1
 
The definition under which most plans pay STD benefits is usually that you are unable to perform the material duties of “your own occupation.” This means that if your doctor and your medical records adequately document that you are unable to perform your own job, then you will be eligible to receive STD benefits. The STD period is typically 6 months, although this may vary from plan to plan. After you have  been continuously disabled for 6 months (or whatever the STD period is under your plan) and have been paid benefits, you will then become eligible for LTD benefits.
 
Key Concept #2
 
Under most ERISA disability plans, you will find that for LTD benefits, the definition of “disability” changes from own occupation (“own occ”) to any occupation (“any occ”). This means that your doctor and your medical records must document that you are unable to perform any job (for which you may be suited), not just your own job.
 
Key Concept #3
 
Proper Medical Documentation is Critical. During the time you are receiving benefits in STD, your medical documentation must anticipate the change in the definition of “disability” from own occ to any occ; for LTD benefits; therefore documentation in your medical record that would establish that is going to be a critical factor.
 

LTD Benefits Denial: Essential Considerations

Uneven Playing Field:You cannot assume that your LTD insurance carrier will put your interests first. Policies are carefully written and crafted to tip the scales in the insurer's favor. Denial of claims saves them money since the majority of people denied either miss deadlines, don't hire counsel or file a claim in Federal Court (ERISA wrongful denial). Hiring counsel is therefore critical at the moment your LTD claim has ben denied.

Medical Documentation:   Your doctor will not necessarily provide the proper documentation that you need to support your disability claim. Some doctors don't want to be bothered with all that paperwork. Others don't understand what is needed to create a properly documented medical file including details connecting your medical condition to how the condition limits and prevents you from performing your past job or any job.

So-Called Friends:   Do not rely on the LTD carrier or your employer's HR department to help you. They have an inherent conflict of interest; their primary allegiance is to their employer and not to protecting your interests.  

Conclusion:   Many claimants rely on the misconceptions above described and are denied; they face the daunting task of taking the claim to Federal Court. Instead, expect a hard fought battle from the outset requiring legal expertise to ultimately litigate an ERISA claim in Federal Court.   

ERISA law is complicated. At Law Med, we are ERISA knowledgeable and experienced. 

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