How Does ERISA Affect My Disability Claim?

November 15, 2012

If you have been denied short term or long term disability benefits, you may have noticed information in your denial letter about The Employee Retirement Income Security Act of 1974, or "ERISA." ERISA includes regulations for all employee benefits that are offered by private employers, including your group health and disability insurance.

Which Employee Benefit Plans are Covered by ERISA?
ERISA governs most private employee benefit plans, including disability and health insurance plans.

Which Employee Benefit Plans are Exempt from ERISA?
ERISA usually does not cover employee benefit plans offered through public or church employers. If you're an employee of a public school or a church owned hospital, your employee benefit plan may be exempt from ERISA. Additionally, "salary continuation plans" may also be exempt from ERISA.

My ERISA Claim Has Been Denied. Now What?
If your ERISA claim has been denied, you must first file an appeal. ERISA allows the claimant to seek legal representation during the appeals process and O'Ryan Law Firm may be able to help you.

Appeal
ERISA describes the number of days allowed to appeal and also the number of days in which the insurer has to make a decision. During the appeal process, the claimant has the right to request the administrative claim file that the insurance company has created. ERISA law specifies that the employee's claim file must be sent within 30 days of a request.

ERISA law states that a claimant must appeal a denial within 180 days. If a claimant fails to appeal by this deadline, they could forfeit their claim for disability benefits. The appeals process is very important and must contain relevant medical and vocational evidence.

Once the claimant has appealed, the insurance company has a maximum of 90 days to make a determination. If the insurance company's review will take longer than 45 days, then the insurer is to notify the claimant in writing that more time is needed.

Lawsuit
In most situations, the claimant must exhaust the appeals process before they are permitted to file a law suit in court. Because ERISA claims are governed by a federal act, the claimant must file a lawsuit in federal court. The deadline to file a lawsuit is usually included in the employee benefit plan.

Unfortunately, the judge's review of the ERISA claim is generally limited to the evidence that was supplied during the claim review process and appeal. That means that the claimant does not have the chance to submit supportive medical information after their last appeal has been denied. Therefore, the appeal phase is extremely important to a claimant's chances of success.

Additionally, ERISA cases are not entitled to a jury trial. Rather, the judge is the sole determiner of the lawsuit. The judge usually makes his or her determination by reviewing extensive legal briefs by both the Plaintiff and Defendant.

Contact O'Ryan Law Firm
Because the rules of ERISA are complicated and O'Ryan Law Firm has a wealth of experience handling every step of the ERISA claims process, we may be able to help you if you have been denied disability insurance benefits.