If you purchased your disability insurance policy through your employer using a paycheck deduction, then the law that covers your complaint about being wrongly denied disability insurance benefits is a federal law known as ERISA.
ERISA was originally designed to protect employees’ pensions, but it is now applied to disability insurance companies in a way that gives them greater control over the appeals process when people bring complaints about disability claims denial.
Far from “protecting” the benefits employees paid for, ERISA has made it extremely difficult for sick and injured people to fight back when they have been wrongly denied disability insurance benefits.
One of the first challenges is that of proving a disability.
Proving a Disability
Having a diagnosis is the first step in getting disability benefits, but a diagnosis is not a disability. If you have experienced a disability insurance benefits denial, there are three elements that come together to prove a disability. The first is a diagnosed illness or injury. The second is proving limitations and restrictions. The third is demonstrating how those limitations and restrictions interfere with your specific job. Diagnosed Illness and Injury: It seems a simple matter to get a medical diagnosis from your doctor, but when fighting a disability claim, insurance companies sometimes:
- Refuse to recognize an illness as disabling (such as chronic pain conditions, chemical sensitivities, or long COVID)
- Refuse to recognize the severity of the symptoms (they may say that the symptoms are subjective)
- Choose to ignore the way that multiple medical conditions, added together, worsen the degree of disability
Documented Limitations and Restrictions: Limitations are things you physically cannot do. For example, if you have a back injury, you physically may not be able to bend or stand for long periods of time. If you have lost eyesight or hearing, you cannot see or hear. If you have narcolepsy, you cannot reliably stay awake.
Restrictions are things you should not do because they can do further harm. For example, if you have a rotator cuff injury or tendonitis of the shoulder, you may be restricted from lifting or working overhead. It will worsen the injury. If you have a serious heart condition, working in a high-stress job could increase your chances of a heart attack. Your doctor may restrict you from high-stress work.
Interference with Job Duties: It’s possible to have a serious illness – like multiple sclerosis or diabetes – and still be able to perform the “material and substantial duties” of your job with “reasonable continuity” (most of the time). It depends on the severity of your illness/injury and the type of work you do.
Just because you have the same job title as thousands of other workers, that does not mean you do the exact same job that they do. Insurance companies have been known to misrepresent or misinterpret the tasks and duties of an occupation.
You – and your ERISA appeals attorney – will need to carefully document each of these areas when preparing an appeal of your disability insurance denial.
ERISA law is so complex and detailed that most lawyers do not handle it. If you are appealing the denial of long-term disability insurance, work with an experienced ERISA appeals attorney. Contact The Fell Law Firm at 972-450-1418 or email us.