Do You Need a Lawyer to File for Long Term Disability in Pennsylvania?

How to Apply for Long Term Disability in Pennsylvania

Long Term Disability Insurance provides insurers with income if they become ill or injured and cannot work for a certain period of time.  Most policies are an employer-provided policy governed by ERISA, the Employee Retirement Income Security Act.  To receive benefits, employees must file a timely proof of loss and disability claim.  While many workers wait until a claim has been initially denied before obtaining representation, it is often wise to pursue representation at the onset.

Understanding Your Long Term Disability Insurance Policy

There are numerous subtleties and complexities in policies and it is often times wise for an employee to have these policies explained by a competent New Jersey ERISA attorney.  For example, policies may differ as to the definition of disability.  Some policies provide that a person is deemed disabled if they cannot perform the substantial duties of their own occupation.  This is often referred to as an “own occupation” policy. Other policies, define a definition of disabilities differently.

There are many other differences among policies such as the effect or offset of other income, how monthly benefits may be calculated as well as tax consequences of these benefits.  Additionally, each insurance carrier or Plan Administrator has different forms of varying complexity. Many times, incorrect completion of these forms can cause unnecessary delay or ultimate denial.

Finally, oftentimes prior to making a determination, an insurance company may want an in-person or telephonic statement from the employee.  It is important that the employee understands that the statements provided may have significant consequences and it is important that the employee fully understands the policy prior to providing this information.  It is important for the employee to keep in mind that a natural adversarial relationship exists between the employee and the benefit provider in that thousands of dollars in benefits may be at stake. Unfortunately, a small misstatement in an application or in an in-person or telephonic statement may be the reason an insurance carrier provides in denying paying benefits.

What to Do if Your ERISA Claim is Denied

When a Long Term Disability carrier has issued a denial for benefits, it does not mean that that determination is accurate.  Oftentimes, a denial is based upon either a mischaracterization of your illness or injury, a claim in which the insurance carriers were not given full and completely accurate information from your providers, or based upon an insurance-hired doctor who provides a cursory review of your file and makes a determination that you are not disabled.  A further reason for denial can be surveillance by an insurance company private investigator who suggests that your daily activities are not consistent with a disability. These determinations are oftentimes unfounded and should be fought vigorously.

How to Appeal a Long Term Disability Claim Denial

First and foremost, the appeal must be made in a timely manner.  The time period for appeal is based upon the actual policy language.  While most policies provide language for 180 day appeal period, this can often be extended if further information is needed to be obtained.  It is important to note that if you failed to appeal in a timely manner, very limited grounds exist to continue with your appeal. It is important that prior to completing your appeal, you obtain the full administrative claims file.  It is a requirement that the carrier provide you or your counsel with the complete internal file. You have an absolute right to this file and it is often very revealing to determine how accurately the evidence of record was evaluated.  More so, a review of the claims file in conjunction with the denial letter, often provides a transparent look at the predispositions of the evaluators. Not only do you receive the medical evidence but also their internal conclusionary comments.

After reviewing the file in conjunction with the denial letter as well as your doctors’ medical evidence, a comprehensive strategy should be formulated.  Is the medical evidence that was provided sufficient, or will it need to be supplemented? It is important that your most relevant medical providers be contacted to see if they will provide the medical support necessary in addressing the medical issues that may need to be addressed in your claim.

How to Successfully Appeal an ERISA Claim

In order to be successful in an ERISA claim, in most states, the standard is “arbitrary and capricious”.  The arbitrary and capricious standard is a review that applies in most ERISA long term disability claims.   According to this standard, a plan administrator’s decision will not be deemed arbitrary and capricious so long as it is possible to offer a reasonable explanation based on the evidence for the particular outcome.  Thus, the standard is inherently in favor of an insurance carrier by requiring that the Claimant prove the claims reviewer who denied your claim acted in an “arbitrary or capricious” manner during the denial process, i.e. without consideration or regards for facts and circumstances presented or on a whim without well thought out reason.

Since in an employer-based policy there is such a difficult standard, it is that much more crucial that the fact finder, i.e. the insurance carrier be provided with such overwhelming evidence that the arbitrary and capricious standard can be met.  It is important to inundate the carrier with overwhelming evidence to support that any finding against a disability applicant could only have been “arbitrary and capricious” based upon the evidence provided. Since many of these policies also have an own occupation provision, your counsel may suggest that a Vocational Expert provide an evaluation as to the limitations you have as to your own occupation as well as to any other occupations that your skills may transfer to.  Rarely (if ever) is a Vocational Expert’s testimony provided for by the insurance carrier supportive to your claim.

Finding an Attorney for Yout ERISA Appeal Lawsuit in Federal Court

Upon a final administrative denial, if your claim is an ERISA claim, it must be appealed to federal court.  Private policy appeals can often be brought in either federal or state court depending on the language. However, for purposes of this article, we are dealing with ERISA claims since they are the majority of the claims that reach this level.

You cannot bring a lawsuit on an ERISA claim unless you have exhausted your administrative claims by filing all appropriate appeals.  Furthermore, unlike a private policy claim where a Claimant will have an opportunity to testify, in a lawsuit against your insurer in an ERISA claim, you are almost always prohibited from introducing new evidence including testimony.

Therefore, the federal judge, with extremely limited exceptions, decides your case based on what is already in the administrative record.  This may be the biggest mistake Claimant’s make in pursuing long-term disability claims – they wait to contact an ERISA lawyer until after their administrative remedies have been exhausted.  Since your record is now completed, at that point, the opportunity for success is extremely limited.  No records can be supplemented, no Vocational Expert testimony can be proffered. Therefore, not only are you facing the very difficult arbitrary and capricious standard, but you are often bound by an incomplete and unpersuasive record.  Therefore, it is imperative that a Claimant contact counsel far in advance of the administrative record being closed, otherwise your chance of success is greatly compromised.

Our Long Term Disability (ERISA) Attorneys Can Help

Long Term Disability policies are complex in their structure.  Likewise, since insurance companies often have thousands of dollars at stake, there is a natural adversarial relationship that exists.  Furthermore, if it is an ERISA policy, the standard of review is extremely difficult for the applicant. It is important, almost mandatory, that you consult with an extremely experienced ERISA attorney in this field as early in the process as possible.  Most experienced ERISA attorneys in this area of practice will not charge a consultation fee and many will handle the claim on a contingency fee basis.

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