Skilled ERISA Lawyers Serving Los Angeles, California

The Employee Retirement Income Security Act (ERISA) of 1974 is a piece of federal legislation that governs almost all employer-sponsored insurance plans for employees. If you receive group short- or long-term disability insurance coverage as part of your employment compensation in Los Angeles, ERISA is most likely the law that sets out the basic standards for this coverage.

Insurance carriers know how to take advantage of the legislation’s complexities to delay paying insurance benefits to claimants, or to refuse to payout altogether. If you’re in this situation, you need a Los Angeles ERISA attorney on your side.

What Am I Entitled To Under An ERISA Short- Or Long-Term Disability Insurance Policy?

Under an employer-sponsored long-term disability insurance plan, you’ll be guaranteed certain basic features under the governing federal law. ERISA sets out requirements in terms of employers’ funding of disability insurance policies and imposes other responsibilities on employers related to group disability insurance plans as well. The legislation also creates minimum requirements for any insurance plan that qualifies as an ERISA policy.

The legislation takes precedence over all relevant local and state regulations that exist in Los Angeles and California. While local and state laws may offer you extra protection in some areas, ERISA sets minimum federal standards for group disability policies that state courts and governments must adhere to. Significantly, this means insurers cannot attempt to reduce their liability in relation to claims by crossing state lines.

ERISA rules generally do not apply to long-term disability insurance policies provided by churches or government agencies.

What’s The Difference Between ERISA Policies And Individual Long-Term Disability Insurance Plans?

It’s important to understand the distinction between individual and employer-sponsored group long-term disability insurance plans in terms of policy features and legal implications. Remember, ERISA only applies to employer-sponsored policies.

If you file a claim in relation to an individually purchased long-term disability insurance policy and your carrier rejects it, you can skip the appeals process and take the company to court. If you win your lawsuit, you’ll receive your benefit entitlements along with damages and legal fees. However, in an ERISA case, it’s not that simple.

The legislation does not allow group disability insurance claimants to call witnesses or introduce evidence outside of what’s in your “administrative record.” This is the collection of documents used during the administrative appeals process following an initially rejected group ERISA claim; insurance companies can sometimes play down the importance of a thorough comprehensive appeal, leading you to make grave errors during the appeal process. Also, you’re not entitled to a jury trial as an ERISA claimant.

Overall, ERISA rules are more unfavorable for claimants than the laws around individual long-term disability insurance.

Policy Terms

Individually-purchased policies typically offer tax-free benefits and better terms than insurance you receive as a perk of employment. Percentages of income recoverable through monthly benefits, elimination periods, definitions of disability, and exclusion clauses will all generally be more favorable for you under an individual plan.

If you’re concerned that your employer-sponsored policy doesn’t offer sufficiently comprehensive coverage, you can supplement the policy with an individual plan. Say, for example, your group coverage will replace 60% of your working income, after an elimination period of 180 days, if you develop a disability. You can purchase a supplementary long-term disability insurance policy that will begin paying more comprehensive monthly benefits after a shorter elimination period. Once the coverage from your ERISA policy kicks in, your individually purchased supplement will only have to make up the difference.

“Any Occupation” Or “Own Occupation?”

Most employer-sponsored group disability policies use an “any occupation” definition of disability. This means your insurance carrier won’t regard you as disabled until your condition prevents you from carrying out the tasks associated with any occupation for which you are trained, educated, or suited. Even if your symptoms prevent you from working full- or part-time in the role you had prior to the onset of your condition, you will not be disabled under the terms of your policy if you can get another suitable occupation.

An “own occupation” definition of disability is more generous to insured parties. Under these terms, you will be regarded as having a compensable disability once your symptoms prevent you from working in the position you held before the onset of your condition. Even if you could get another suitable full- or part-time job, you will remain entitled to full monthly benefits.

Remember, “own occupation” definitions are better for claimants, which means they make premiums a little more expensive. Most employers don’t want to pay more than they need to for their employees’ disability insurance, which is why group policies usually have “any occupation” disability definitions.

What Can A Los Angeles ERISA Attorney Do For Me?

If you’ve already filed a claim for monthly benefits under an ERISA policy only for your insurer to reject it, don’t panic. The legislation sets out a process through which any claimant can or must file an appeal.

To give yourself the best chance of success, you need to obtain your administrative record from your insurer without delay. This will give your attorney the chance to highlight how the carrier may have made mistakes when deciding not to issue benefits in your case. Also, it will allow you to counter the company’s approach with any relevant medical records, testing, RX’s, and before and after you were unable to work. Remember, you cannot introduce evidence in court outside of what’s in your administrative record.

Under the Federal Arbitration Act (FAA), contractual agreements to settle disputes through arbitration are enforceable. This means your employer may be able to compel you to settle any disability insurance dispute in arbitration, rather than in court. If this happens in your case, you’ll need a lawyer with experience in ERISA arbitration.

Remember, your employer’s HR department won’t necessarily be on your side during a claim. Successful claims drive up premiums for employers, giving them an incentive to want your claim to fail. When you’re seeking assistance with an ERISA claim in Los Angeles, your lawyer is the only person you should trust.

Speak With A Los Angeles ERISA Attorney Today

If your physician has diagnosed you with a sickness or accident that’s preventing you from executing the duties associated with your full- or part-time occupation, but your insurance provider is refusing to pay the monthly benefits you’re entitled to, don’t hesitate to act. Enlisting the help of a Los Angeles ERISA attorney is the best way to prevent your disability insurer from taking advantage of you.

Contact DarrasLaw to schedule your free initial consultation today, policy analysis, or claims assistance. We can help you build an ERISA case from scratch or plan your appeals process if your insurance carrier has already rejected your initial claim.