ERISA Experience You Can Rely On.


On Behalf of | Nov 1, 2023 | Firm News

As a result of your employment, you have group benefits – disability benefits, life insurance, accidental death & dismemberment insurance, medical benefits, pension benefits.  Your employer provided you with a copy of the insurance policy or certificate, or the plan or summary plan description (SPD).  So, you know what your rights and benefits are.  Or do you?  Insurance policies, certificates, benefits plans, and SPDs are complex, confusing documents often written in “legalese” that even lawyers do not understand.  If your group benefits – disability benefits, life insurance, accidental death & dismemberment, medical benefits or pension benefits – have been denied, you need to know what your rights are and what you need to do to get your benefits. Surprisingly, the plan documents – insurance policy, certificates, group plan, SPD – often do not say what they mean or mean what they say.  To enforce your rights and get the benefits to which you are entitled, you need to know what these documents actually mean.


If your group benefits have been denied or terminated, the ERISA Law Center can help you. We have extensive experience representing persons to obtain disability benefits, pension benefits, life insurance and accidental death and dismemberment benefits, and medical benefits and we know what the insurance companies and group plan administrators don’t tell you and don’t want you to know: that insurance policies and group plans frequently do not mean what they say.  Sometimes, the real meaning of the policy or plan is hidden.  The ERISA Law Center can help you understand the meaning of your policy or plan and get the benefits to which you are entitled.


Here are some real life examples of “hidden” policy terms:


  • Your insurance policy states that disability benefits due to a mental disease or disorder are limited to 12 or 24 months; the claimant is disabled by depression, anxiety, and other mental diseases and by a physical condition.  The insurance company terminates your benefits stating they are limited by the mental illness limitation.  You may still have a right to benefits.  Maybe.  Many of these limitations are ambiguous.  The law has special rules when insurance policy provisions are ambiguous – so you may be entitled to continued benefits despite a mental illness limitation which appears to end those benefits.  But you need to investigate how the limitation will actually be applied.


  • Your claim for disability benefits is denied because your insurance company says your disabling conditions are excluded from coverage due to a preexisting condition limitation.  A policy term that says if you received or if a reasonable person would have received medical treatment during a specified period of time before you became covered by the policy, you are not entitled to benefits.  You did receive such medical treatment.  Does that mean you are not entitled to benefits?  Maybe not.  Many states limit or control the content of such pre-existing condition limitations.  If the policy that covers you was issued in a state which regulates the terms of such preexisting condition limitations (and that state may not be where you live or worked or even where your employer operates its business), and if the policy language does not follow that state’s requirements, then the preexisting condition may not be enforceable the preexisting condition limitation written in the policy may not therefore apply to your claim , and you may be entitled to benefits.  But you may need to determine whether a “hidden” term means the preexisting condition limitation is not acceptable.


  • You are injured in an accident or the person whose life is insured is killed in an accident.  The policy excludes coverage or payment of benefits if the insured person was intoxicated at the time of the accident, and the insurance company claims he or she was.  There is evidence of intoxication.  Does this mean you are not entitled to benefits?  Not necessarily.  Many states regulate the terms of such “intoxication” exclusions.  If the policy does not follow the state’s requirements, the exclusion for “intoxication” may not be enforceable and you may be entitled to benefits, despite evidence of intoxication.  But you need to investigate if there is a “hidden” policy term.


  • Your insurance company is paying you long term disability benefits.  The policy states it can reduce the amount of those benefits by any temporary or permanent workers’ compensation benefits you receive.  You receive an award of workers’ compensation permanent disability benefits, and the insurance company claims that that award should reduce your LTD benefits.  Are you out of luck because, after all, that is what the policy says?  Not necessarily.  If the group policy was issued in a state which prohibits reduced LTD benefits by any award of permanent workers’ compensation benefits, then the written terms of the policy cannot legally be enforced, and your insurance company cannot properly reduce your LTD benefits, even though that is what the policy says.


These are actual examples.  At the ERISA Law Center, we have seen many, many more similar claims in which the actual terms of the policy or plan are hidden or ambiguous.  Here is the reality: insurance companies often write ambiguous policy terms or include terms in group insurance policies that are in violation of the law of the state in which the insurance policy was issued and so are unenforceable.  So be aware:  even if it looks like your claim for benefits is a lost cause, there may be ambiguous or hidden terms in the policy which entitled you to benefits and the ERISA Law Cetner may be able to help you get benefits.  Contact the ERISA Law Center using our online form or at 559-549-6490.