Long Term Disability Claims

The largest area of our practice is helping clients obtain long term disability benefits from their insurance companies. If you worked for a company that provided a group disability policy for its employees (ERISA claims), or if you purchased a disability policy on your own, we can help you.

Regrettably, many of the leading disability insurance companies engage in systematic strategies to deny claims. Aided by an ERISA law that gives them procedural advantages, these companies have many means at their disposal to intimidate or outwit legitimate claimants. It is our job to level the playing field for an individual who wants to expend his or her energy recovering from their illness, rather than fighting with an insurance company.

We can assist you with initial claim filings, appeals, litigation, and claim management. We help you communicate effectively with your insurance company and your doctors. We advise you about how to conduct your life in a way that does not harm your case, and how to respond to the actions and requests of your disability insurance company.

Sometimes our greatest value may be an intangible one: sending a message to the insurance company and its attorneys that you are not going to be pushed around.

Short Term Disability Claims

If we have accepted your case for long term disability benefits, we can also help you obtain short term disability benefits. It is common for a client who has been denied long term disability benefits to be put in a situation where they must simultaneously appeal an adverse ruling on their short term benefits and file for long term benefits.

Disability Claim Litigation

The ERISA Law Group can bring suit against a disability insurance company for the wrongful denial or termination of benefits.                

Many of our clients are justifiably angry with their insurance companies, and may see a lawsuit as their only means to obtain redress. If their case falls under ERISA law, they must go through the appeals process before they gain the right to sue.

Some insurance companies are more litigious than others, and pursue a strategy of pushing cases toward a court proceeding. In “overpayment” cases the insurance company may initiate a suit for repayment of benefits already paid, and the claimant must defend against this threat.

Should you have to sue for benefits or defend yourself, our attorneys bring extensive trial backgrounds to the courtroom to prosecute your case.

Fortunately, disability claims can often be resolved out of court once the insurance company sees that an effective case has been prepared on behalf of the client.  Both sides understand that litigation is time consuming and expensive. We may file a successful appeal that is approved by the plan administrator, or we may negotiate a settlement or a buyout. In all cases, the client retains the right to approve a final settlement. Learn More

ERISA Disability Claim Appeals                       

If your long term disability claim is denied, or if you have received a letter terminating your existing benefits, in many cases you can file a successful appeal.

Not only does the appeal give you a chance to overturn the decision, but it is also a required step in order to preserve your right to file a lawsuit at a later date.

The appeal must be filed in accordance with the procedures and deadlines specified in your disability plan. If you don’t have your policy documents by now, you must obtain them quickly from the plan administrator.

The most important thing to keep in mind is your deadline, because you are usually limited to a two or three-month time period.  You have to use this time very effectively.            

The appeal stage is your last opportunity to make the administrative record as complete as possible. (This record is the legal term for all the evidence submitted to the insurance company.)  Once the appeal process is complete, the record is “set in stone.” Should you later file a lawsuit against your plan, the judge will only look at the existing administrative record. If you have not submitted enough supporting evidence, or the right type of evidence, you could lose your case regardless of how sick or disabled you may be.

Negotiating Disability Settlements and Buyouts    

ERISA Law Group attorneys frequently negotiate settlements and buyouts for our clients.  A successful case usually results in reinstatement of benefits or a lump sum payment from the insurance company.

Settlement discussions typically involve calculation of the present value of benefits, the structure and timing of settlement payments, and the status of related health insurance or life insurance coverage.

The settlement process must always be approached with care.  A claimant without an attorney might suggest a settlement to their insurance company.  Contrary to their expectation, their well- meaning suggestion is likely to trigger suspicion.  Why does this person want to settle?  Are they likely to die soon?  After all, if the claimant dies, the disability insurer is finished making payments.  In this situation a settlement offer will lead to even tougher scrutiny from the insurer.

Successful negotiation relies upon knowledge of the legal process and the tactics used by the insurers and their law firms.  There are even traps for attorneys who do not specialize in ERISA disability cases, since the bargaining process sometimes has different unwritten “rules.”

Bad Faith Insurance Litigation

Certain disability insurance claims may not be governed by ERISA. This is likely if one of the following applies:

	You purchased an individual disability policy directly from an insurance company.
	You work for a branch of government - either local, state, or Federal.
	You work for a church.

When ERISA law does not apply, you can file a lawsuit against your disability insurer alleging that their claim denial involved “bad faith” conduct.

Insurance companies have a legal obligation to act fairly and in good faith when evaluating claims from their policyholders. When a company violates that duty by engaging in unfair claim handling practices, they can be held liable for the amount of the claim as well as punitive damages and other damages. The insurance company must also fight the case under legal rules that are much less favorable than the ERISA law.                                  

Any of the following have been deemed to be “bad faith” insurance claim practices:

1) Misrepresenting relevant facts of insurance policy provisions relating to coverage at issue.   

2) Failing to acknowledge and act reasonably and promptly upon communications with respect to claims arising out of insurance policies.

3) Failing to adopt and implement reasonable standards for the prompt investigation of claims arising under insurance policies.

4) Refusing to pay claims without conducting a reasonable investigation based upon all available information.

5) Failing to confirm or deny coverage of claims within a reasonable time after proof of loss statement has been completed.

6) Not attempting in good faith to effectuate fair and equitable settlements of claims in which liability has become reasonably clear.

7) Compelling insured's to institute litigation to recover amounts due under an insurance policy by offering substantially less than the amount ultimately recovered in actions brought by such insured's.

8) Attempting to settle a claim for less than the amount to which a reasonable man would have believed he was entitled by reference to written or printed advertising material accompanying or made part of an application.

9) Attempting to settle claims on the basis of an application which was altered without notice to, or knowledge or consent of the insured.

10) Making claims payments to insured or beneficiaries not accompanied by a statement setting forth the coverage under which the payments are being made;

11) Making known to insured's or claimants a policy of appealing from arbitration awards in favor of insured's or claimants for the purpose of compelling them to accept settlements or compromises less than the amount awarded in arbitration.

12) Delaying the investigation or payment of claims by requiring an insured, claimant, or the physician of either to submit a preliminary claim report and then requiring the subsequent submission of formal proof of loss forms, both of which submissions contain substantially the same information.

13) Failing to promptly settle claims where liability has become reasonably clear under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage.

14) Failing to promptly provide a reasonable explanation of the basis in the insurance policy in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement.

15) Intentionally withholding or misinterpreting information, file documents, or policy provisions to hide facts that would favor the claimant. 

16) Requesting excessive documentation not required by the policy.

17) Using illegal, fraudulent, intrusive, or demeaning investigative methods or procedures which victimize the insured. 

18) Advising claimant not to hire an attorney.

The ERISA Law Group attorneys have successfully prosecuted bad faith insurance cases. If you think you are a victim of bad faith conduct, you should not hesitate to contact us about your case.

ERISA Life Insurance Claims

The ERISA Law Group can represent survivors or beneficiaries who wish to claim life insurance benefits under a life insurance plan that is governed by ERISA.

Most of us assume that an insurance company will stand behind a life insurance policy it has issued. It seems almost unthinkable that when we have suffered the loss of a loved one - not to mention their earning power that may be sustaining the family - we could then be told that the life insurance policy is not valid.

Unfortunately, in too many cases surviving family members or business partners find themselves in this situation.

Sometimes a claim will be challenged because the insurance company alleges that the insured person committed suicide. In other situations the insurance company will argue that the deceased contributed to their own death by virtue of illegal or irresponsible conduct that is not covered under the policy. Other claims may be denied based on an insurance company allegation that the insured misrepresented their own medical condition at the time they submitted the insurance application. If the insurer can find medical records or other evidence that conflicts with the application, they will usually deny the claim.

An attorney from the ERISA Law Group can assist you in obtaining life insurance benefits. We can use many approaches to fight the case. We may prove that a death was accidental, that the insured did not contribute to their own death, or that circumstances were sufficiently unclear as to warrant a reasonable settlement.  We may show that the insurance policy was “incontestable,” or that an alleged application misstatement was based on ignorance, or that the insurance company could have uncovered the health condition through its own physical exam and investigation at the time of the application.  In some cases consumer protection laws of a state like California might take precedence over an insurance company contract clause.

Overpayment Cases                                                   

Claim rejections are not the only perils that can befall disabled employees. You might be happily receiving benefits when you suddenly receive a frightening letter from the insurance company or a collection agency demanding repayment of thousands of dollars in back benefits.

This situation most frequently arises from the miscalculation of offset payments, but may also occur for other reasons. Whatever the source of the problem, there may be a misinterpretation of the contract or a mistake made by the insurance company, for which you should not be held liable.  The ERISA Law Group attorneys can help you defend against this threat to your finances and your credit standing.

Advice and Counsel

One of our most important tasks at the ERISA Law Group is to provide advice to our clients on how they should conduct themselves during the claim process.

Will I jeopardize my claim if I work at a less demanding job with my employer? How do I conduct myself if I think I am under surveillance by the insurance company? Can I go back to school?

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