ERISA, which is short for the Employee Retirement Income Security Act of 1974, may be referred to in your denial letter. LTD law is complex.
This federal legislation, found at 29 U.S.C. §1001 et seq., was designed to protect the pensions and retirement plans of American workers. Unfortunately, it also had the effect of granting partial immunity to insurance companies that handle disability insurance claims, in that state-law based claims for bad faith or mental anguish are pre-empted, or superseded, by ERISA. Accordingly, many disability insurers play “hardball” and have little intention of reviewing disability claims fairly.
Generally, under ERISA, once the internal appeals are exhausted and a lawsuit is filed, no additional evidence can be submitted. The federal courts conduct what is called a “judicial review of the administrative record” (i.e. the claim file). Under ERISA and its applicable LTD law and regulations, there are no trials, depositions or hearings. Typically, neither the claimant nor the treating physician(s) are allowed to testify, and the Court simply reviews the medical and vocational proof already in the claim file. In most ERISA governed cases, federal courts are to defer to the insurance company’s decision so long as there is a rational basis and reasoned explanation for the decision.
Courts will overturn the insurance company’s denial only if the claimant shows that the denial was “arbitrary and capricious.” This is the highest burden of proof in civil cases, similar to “beyond a reasonable doubt” in criminal cases. And while the insurers are to consider whether the claimant has been determined to be disabled by the Social Security Administration, insurers are not bound by that determination.
Under ERISA , the best a claimant can do is recover the past-due disability benefits that are owed and have their monthly disability check reinstated. There are no consequential, bad faith or punitive damages, and attorney fees are rarely awarded. LTD law is relatively hostile to the Claimant.
Long Term Disability insurance claims are complicated, involve short deadlines and are governed by various laws and regulations. There are many case-law made rules, and numerous legal issues involving overpayments, offsets, limitations of benefits due to mental illness or self-reported conditions, waiver of life insurance premiums, coordination with health insurance, and exclusions for pre-existing conditions.
Evensen Law Office can help you with your LTD claim, appeal or lawsuit, whether your LTD policy is part of a group Long Term Disability Plan or an Individual Disability Income policy. We know LTD law and can help you with your LTD appeal and / or lawsuit.
Evensen Law Office represents disability claimants in claims against the major disability insurance companies, including UNUM Provident, Metlife, CIGNA / LINA, Anthem, Aetna, Lincoln Financial, Prudential, MassMutual, The Standard and the Hartford.