Employee Retirement Income Security Act (ERISA)

If you are seeking short-term or long-term disability benefits, you should discuss your claim with experienced counsel immediately. Disability law is complex and filled with intricacies because it is normally controlled by the Employee Retirement Income Security Act (ERISA). Effective representation during the claims process often avoids the termination or denial of benefits. If you are applying for short term or long term disability benefits, or your claim has been denied, call for your free consultation today or send John Dupree an e-mail via the online contact form. You may want to complete the Disability Information Form and send it with your e-mail so that we have a clear understanding about the nature of your claim. Mr. Dupree will respond to your e-mail promptly.

John Dupree has devoted himself to helping people overcome the difficulties encountered when seeking disability benefits through an insurance company. Mr. Dupree normally works on a contingency basis - this means that he only gets paid if you are awarded benefits.

Below, you will find more information on the following topics:

• What is ERISA?
• Short-term and Long-Term Disability Plans Generally
• The Application Process
• Entitlement to Benefits
• How Benefits are Calculated
• What Happens if Your Claim is Denied?

What is ERISA?

In 1974 Congress passed the Employee Retirement Income Security Act (ERISA) for the purpose of protecting benefits for employees. Before ERISA, unregulated insurance companies could play with the money and change benefits without hindrance. Now, almost all employee benefits are controlled by the terms of ERISA - this includes health insurance, pension and disability insurance. However, ERISA is a complex and extensive area of the law for which legal representation is probably advisable.

If you are applying for disability benefits, keep in mind that your well-being is not necessarily in the interest of the insurance company - after all, it loses money if it pays your benefits. Also, the insurance companies have refined the way that they administer disability claims over the years. Their consultants have been trained to phrase opinions in certain ways, the policies have been redrafted to close any loopholes or paragraphs that help claimants, the adjusters are trained to find ways to deny claims (and many times receive bonus compensation based upon the profitability of the company - ie. - the more denials, the more profitable the company), and the insurance companies have a stable of lawyers that can work for them at any time.

Short-term and Long-Term Disability Plans Generally

Short-term and long-term disability benefits are available to those persons who become unable to work because of an injury or disease and who are covered under a disability policy either individually or through their employer. Short-term and long-term disability claims are different from worker's compensation claims because you do not have to be injured on the job in order to be eligible for benefits. Short-term and long-term disability claims are different from Social Security disability claims because you or your employer usually pay a premium to a private insurance company for coverage under a policy. Typically, your employer offers you the opportunity to enroll in a disability policy and will then automatically deduct your premium from your paycheck.

The Application Process

If you become unable to work because of an injury or disease, you should notify your insurance carrier and employer immediately and inquire about filing an application. Your employer will usually have the necessary forms and information to apply for the benefits and can help you with the process. However, it is a good practice to always keep yourself involved with the process because ultimately if a form is not filed in a timely manner or a problem arises, you are the one who does not receive the benefits. Therefore, follow-up with your employer and the insurance company to make sure everything is proceeding smoothly.

The application itself typically has several sections. An "Attending Physician's Statement" is normally a part of the application. This statement requires that your treating physician answer certain questions with regard to your claim. Usually, the form requests information regarding the diagnosis, objective findings and your ability to continue employment. In addition, usually there is a "Employer's Statement" that needs to be completed by your employer. This form advises the insurance company about the details of your pay, your job duties and other information necessary to process the claim. Again, remain active in making sure that your physician and employer completes this form and sends it to the insurance company because your application will not be accepted without it.

You will also normally fill in a section of the application called the "Claimant's Statement." The form usually requires you to provide general information about yourself and a description of your injury or condition. There should be questions pertaining to your ability to work and questions regarding other sources of benefits such as worker's compensation or Social Security. Do your best to answer these questions as completely as possible. If the insurance company has any further questions or needs clarification for an answer, provide the information promptly.

It is important to be aware that once the application process and any subsequent appeal process is complete, under normal circumstances no new information may be submitted to help your case - even during a subsequent lawsuit. Hence, it is probably advisable to retain counsel to help you through the process at an early stage before it is too late to submit evidence that can turn the case in your favor.

Entitlement to Benefits

The normal disability benefit policy has two stages of entitlement. Usually there is a short term period where you would be entitled to benefits if you are unable to perform each of the material duties of the occupation that you regularly perform for your employer. This is normally referred to as an "own occupation" provision. This period of benefits usually lasts for two years or so long as you are unable to perform your normal job. After the two years expires, the requirement for benefits will normally change.

After the initial two year period, you will probably be required to show that you are unable to perform each of the material duties of any occupation for which you are suited given your education, training and experience. This is an "any occupation" provision. These benefits usually last until you reach normal retirement age or until your condition improves to the point that you may return to employment in a job suited to your background. These are known as long-term disability benefits.

During these two benefit periods, your insurance company will probably require you to periodically send in proof of your continuing disability. Usually, the insurance company requires your physician to complete a form and submit it to the company. Once again, stay involved with this process to make sure the forms arrive at the insurance company because you will not want an interruption of your benefits.

How Benefits are Calculated

Normally, benefits equal 60% of your base pay immediately prior to the beginning of your disability. Bonuses, overtime pay and other extra compensation are not normally considered when calculating the benefit. Therefore, if your salary is $2,000.00 per month, then your disability benefit would be $1,200.00 a month before any offsets that may apply.

Usually offset provisions are set forth in the policy. Thus, if you receive benefits from a worker's compensation claim or a Social Security claim, then these benefits would be subtracted from the amount that you would be entitled from your disability policy. Therefore, in the above example, if you receive $600.00 in Social Security benefits, then your disability check would equate to $600.00. Finally, the usual disability policy provides for maximum and minimum monthly benefits.

What Happens if Your Claim is Denied?

If your claim is denied after the initial application process, you may normally appeal the decision. However, at this point, if you are not already represented by a lawyer, you may want to consider seeking the help of an attorney familiar with disability claims procedures. This course of action may be advisable because, as set forth above, usually the insurance company will allow you to submit additional evidence supporting your claim during the appeal process. An attorney may be able to help you organize and develop your medical evidence or address other issues that may be preventing the insurance company from rendering a decision in your favor. Should the insurance company determine that its initial decision to deny benefits was correct, then your last option is to pursue your claim in court.

Click here to download the Disability Information Form, or contact an attorney online by clicking here.