Individuals who file claims for disability benefits often have few other options for supporting themselves. Employers sometimes offer long-term disability and short-term disability policies as part of benefits packages. The average worker probably hopes to never use their disability insurance, but life is anything but predictable.
A car crash, a cancer diagnosis or a variety of other unexpected experiences could render someone incapable of working for an extended time or possibly for the rest of their life. That employee could then file a claim for long-term disability benefits, which could help them cover basic expenses when they are unable to work.
Unfortunately, not everyone quickly gets benefits despite theoretically having a disability policy provided by their employer. Some workers have to appeal to get approval for their claims. In fact, they may even need to take the matter to court. Being thorough when pursuing an appeal can impact someone’s rights if the appeal is unsuccessful.
There may only be one appeal available
Under the Employee Retirement Income Security Act of 1974 (ERISA), workers seeking to use disability benefits provided by their employers have certain rights. The insurance company has a fiduciary duty to policyholders. The company should make decisions that prioritize the best interests of those with a policy rather than the company’s finances.
Additionally, every claimant has the right to a single appeal. If the appeal is unsuccessful, policyholders could try to take legal action in civil court. However, during that process, there is a limit to the evidence that they can present to the judge hearing their case. Specifically, they can typically only use evidence already presented to the insurance company and used when considering their initial claim or processing the appeal. It is crucial to have adequate medical documentation validating the severity of someone’s medical limitations during the appeals process.
Otherwise, there may not be enough proof that the insurance company made the wrong decision and violated the rights of a policyholder by doing so. Workers preparing for an ERISA appeal might need to undergo specialized medical examinations and discuss their cases at length with professionals familiar with the nuances of ERISA.
Being assertive when appealing ERISA long-term disability coverage decisions can make a major difference for an applicant in need of benefits. Employees who have adequate medical documentation during their appeals often have stronger claims if they must take their cases to court.
