ERISA and Disability Benefits

The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that regulates the retirement plans of private employers. Although ERISA primarily focuses on retirement plans, it also has provisions affecting other employee benefits, including any disability insurance plans. It is important for employees covered by employer-sponsored health and disability insurance plans to understand ERISA's protections, as well as its requirements, in order to protect their rights.

Basics of ERISA Disability Benefits

ERISA only affects disability insurance benefits that are offered by an employer as part of an employee benefits package. ERISA would not apply to private disability insurance plans that workers buy on their own.

When employees have an ERISA disability benefits plan, ERISA's regulations control nearly every aspect of the plan and how employees obtain the plan's benefits. ERISA requires the employer to provide employees with information about their disability benefits, including:

• Detailed explanations of what is covered under the plan and what is not;
• Directions on how to file a claim if the employee becomes disabled; and
• Outline of the appeal process if a claim is denied.

Once an employee files a claim, ERISA sets time limits for the insurance provider to decide the claim. An insurance provider must decide whether to accept or deny a disability claim within 45 days of filing. However, this time limit can be extended by 30 days by notifying the employee.

If a claim is denied, the insurance provider must explain why in writing. ERISA also controls the deadlines for employees to file an appeal and another deadline for the insurance company to decide on whether to approve or deny the appeal.

If an appeal is denied, the employee may file a lawsuit under ERISA. In an administrative hearing, a judge will decide the case.

ERISA and Disability Claim Lawsuits

If a worker's appeal is denied and they followed the ERISA guidelines, the next step may be to file a lawsuit arguing that the insurance company acted improperly in denying benefits. In these lawsuits, ERISA allows judges to review for an "abuse of discretion" only. In short, this legal term simply indicates that the judge's ability to review and overturn or reject the decision being challenged is very limited.

In addition, the judge will only look at the policy holder's file with the insurance company in making their decision. This file is maintained by the insurance company and contains all of the documents related to the policy holder's insurance plan, claims, denials, and appeals.

This is why providing as much supporting information as possible (doctor's reports, letters from employers, etc.) during the administrative appeal process is so important. Without documentation, the judge may have to defer to the insurer or plan manager's reasoning for their denial letter.

What ERISA Means for Your Disability Claim

Although ERISA was intended to protect employees' rights and benefits, its complicated requirements can make it difficult for an employee to file a claim. If a worker does not follow ERISA's requirements to the letter, particularly with deadlines and claim requirements, their claim may be denied with no opportunity to appeal.

Additionally, if an employee skips a step in the ERISA disability benefits claim process (such as skipping an appeal), a future claim in court may not be allowed to proceed.

Have Questions About ERISA and Your Claim? Get Legal Help Today

If you are considering filing a disability claim for an ERISA-regulated employee benefits plan, or just have general questions about disability insurance, it's important to get started right away. You may need to work with a disability attorney in addition to conducting your own research if your case is particularly complicated.