ERISA Disability Denial Attorneys | ERISA Claim Appeals

Atlanta, Georgia, ERISA Attorneys

For most American workers, the benefits that come with one’s job are a substantial portion of the employer’s total compensation package. One of the most important benefits in that package can be long term disability insurance. Life is full of surprises, not all of them good. When you are covered by term disability insurance through your work, you may feel confident that you still have economic security even if poor health prevents you from working. Sadly, all too often that confidence turns out to be misplaced. The Georgia ERISA disability denial lawyers at Robinson & Warncke, LLC can restore your confidence by fighting for the insurance benefits you deserve.

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What is ERISA?

The federal government passed a law in 1974 that regulates employee benefits, the Employee Retirement Income Security Act (ERISA). ERISA covers the benefits of workers employed by private companies. Congress intended that ERISA was supposed to provide “enhanced protection” of employee benefits. Unfortunately, the law backfired completely, and it has never been fixed. ERISA now frequently works in the favor of the insurance companies, and consumers would probably be better off if the law was completely dismantled.

How Are ERISA Disputes Different from Denials of Individual Disability Claims?

There are two major drawbacks to ERISA claims compared to an individually purchased disability policy. If a dispute arises relating an ERISA long term disability benefit:

You are not allowed to file a typical lawsuit in which you call witnesses and provide additional evidence or testimony. Before you ever file suit you must submit an “Administrative Appeal” asking the insurance company to review its own decision. If you don’t file a timely appeal, your claim is dead – forever. And the appeal process is full of pitfalls for the unwary and inexperienced. We strongly caution seeking an ERISA expert attorney’s opinion before trying to handle your own appeal.
If the insurance company upholds its denial on appeal, you can file a lawsuit, but the rules of an ERISA lawsuit are different than most any other case, and most of them favor the insurance company. The case is reviewed by a federal judge, but he only sees the insurance company’s claim file – a cold stack of paper. The judge never lays eyes on you or any other witness. And you face an unusually high burden of proof – usually the judge cannot award benefits even if he thinks the weight of the evidence favors your claim. You have to prove the insurance company’s decision was “arbitrary and capricious” or an “abuse of discretion.” This is widely understood to be a difficult burden for claimants and very favorable to insurers.
Under ERISA, even if the insurance companies found to have acted abusively or fraudulently, you may not bring a bad faith claim or seek extra money damages. The court can order the insurance company to pay the benefits plus your attorneys’ fees, but that is not much of a deterrent in our experience.

For all these reasons ERISA invites insurance companies to aggressively deny claims. Why shouldn’t they? Many claimants will get tripped up by the administrative appeal and miss deadlines. Or they will do such a poor job – omitting important evidence – that they have no hope of winning a lawsuit under the “abuse of discretion” standard of review. Of those claimants who successfully navigate the appeal, many will still have to sue for benefits. Some will hire attorneys who do not specialize in ERISA claims. Many non-expert lawyers end up settling these claims for pennies on the dollar.

And for those who hire an expert lawyer, do a good job on the appeal, and then win their lawsuit (after a two or three year battle) the insurer only has to pay the benefits it should have paid in the first place, plus interest and attorneys’ fees. That fraction of poor outcomes for the insurance companies almost certainly does not offset the money saved on the claims the majority of claimants failed to get right. So, again, there is little reason under ERISA for insurance companies not to aggressively deny claims.

Before you even file for long term disability benefits, it is a good idea to speak with an ERISA disability denial attorney who works on these cases as a regular practice area. It can be cheaper to work with an attorney to get your claim accepted at the initial filing than it is to fight a denial.

ERISA law is a specialized area of practice, and very few attorneys have the experience to handle them. We have seen some very bad outcomes in cases where the policyholder was represented by a well-meaning, but inexperienced, attorney.

Disability and the Law

Under ERISA, long term disability policy’s the definition of “disability” can be very different from what most laypeople expect. Most ERISA policies pay benefits for only twenty-four months for being unable to perform one’s “own occupation.” Moreover, tricky definitions of “own occupation” may mean the insurance company more or less ignores the most difficult demands of your job when evaluating your disability.

After twenty four months most ERISA policies stop paying benefits unless you are disabled from performing “any occupation.” This is generally considered a much tougher burden, and many disabled people find their benefits terminated when the policy goes from “own occupation” to “any occupation.” In fact, this transition accounts for the majority of calls our law firm gets on ERISA claim denials.

Most ERISA LTD policies also limit benefits to 24 months for “mental and nervous disorders,” even if the worker is completely unable to work in any job. We have seen these policy limitations applied not only to conditions like depression, anxiety and bipolar disorder, but also to traumatic brain injury and other forms of physical brain damage. We have successfully fought the application of this “mental and nervous limitation” many times, sometimes leading to the payment of many more years of disability benefits.

“Robinson Warncke ERISA Appeal Recovers $950,000 Accidental Death & Dismemberment from Prudential, Proving That Traumatic Brain Injury Led to Total and Permanent Disability”

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Choosing the Right Long Term Disability Lawyer

The wording of a disability policy is often dense, complicated, and ambiguous. Even though your insurer wrote the policy and could have made it as clear as they wanted, the insurer may try to take advantage of unclear or ambiguous wording. While in some legal jurisdictions that is considered illegal conduct, insurance companies do it anyway, and they frequently get away with it.

It is important to have an ERISA disability denial lawyer working for you who understands the complexities of insurance policy language, both when filing the claim and when opposing a claim denial. Your lawyer should be thoroughly experienced and familiar with the tactics these companies employ to avoid paying a claim. The ERISA lawyers at Robinson & Warncke not only know ERISA law, they have helped create ERISA law that helps consumers and holds insurance companies accountable. Very few Georgia attorneys consistently handle ERISA claims, so it is important that you do your homework in order to ensure that you have the best attorney for your case. Your future may depend on it.

Atlanta Disability Attorneys

When you come to the Atlanta law offices of Robinson & Warncke, LLC for help with your long term disability claim, you can be assured that your Georgia ERISA disability denial lawyer understands the ins and outs of both ERISA and state laws. Our attorneys know how to make the crucial link between the medical condition causing the impairment and the inability to perform the job. We will also educate your doctors on the necessity of articulating specific details that make this connection clear.

In the language of ERISA claims, your impairment needs to be defined in terms of

Restrictions, which are activities you cannot do at all, and
Limitations, which are activities that you may be able to perform, but less intensely, less frequently, or more slowly or for shorter duration.

We will examine your insurance policy in the most minute detail. We will analyze your medical records and any existing application forms. We will gather additional documentation to support your claim that is specifically tailored to your policy terms. This can include helpful statements from your family, employer, coworkers, therapist, doctors and other healthcare providers. We will retain all necessary experts for testing and analysis of the evidence. Testing can (and should) include functional capacity evaluations to support physically-based disability claims. For cognitively-based claims we routinely arrange neuropsychological evaluations and/or imaging studies. The use of experts varies depending on the case, but we often employ vocational specialists to analyze the impact of medical restrictions on employability. We have retained radiologists to analyze imaging, world-reknowned brain injury experts, and medical specialist of every stripe. We will then share all this new evidence with your existing doctor and request an additional and very detailed statement addressing your particular symptoms and the medical evidentiary basis for them.

Our expert ERISA disability denial attorneys will represent you in your Administrative Appeal, which is your final shot at having your claim approved. This is the most important part of the ERISA process, as it is your last opportunity to submit evidence in support of your claim, so it must be prepared with meticulous care to every detail. Our lawyers have an excellent record of having our clients’ cases approved at this level. If the insurance company still refuses to pay, we will file a lawsuit on your behalf. There the “administrative record” goes to a federal judge for review. The preparation that we do in your behalf in the administrative appeal improves the quality of the “administrative record” and pays off in a very large percentage of the cases we accept.