What is ERISA?

ERISA is the federal law that governs employee benefits, including retirement pensions, health insurance, short-term disability insurance, long-term disability insurance, life insurance and some severance plans. ERISA stands for the “Employee Retirement Income Security Act,” and was passed by the U.S. Congress in 1974.

Who does ERISA apply to?

ERISA applies to nearly all private sector employees. It does not apply to government employees. ERISA also does not apply to insurance policies that a person independently purchases – it only applies to insurance that people obtain through their employment.

What are ERISA disability plans?

When employers provide short-term disability and long-term disability benefits to their employees, they do so as part of an ERISA “plan.”  Sometimes the short-term disability plan is self-insured, meaning the employer itself pays the disability benefit while outsourcing the administration of the benefit program to a third party, often an insurance company.  ERISA long-term disability plans are almost always funded by a group insurance policy purchased from one of the large insurers.  ERISA refers to an employee covered under an employer-provided disability insurance policy as a “participant” or “beneficiary.”

What is a summary plan description?

A summary plan description is an overview of the disability insurance plan, explaining what benefits are provided, when a person is eligible for those benefits, and how to make a claim for disability benefits. Sometimes a separate booklet describes the detailed procedures for how to make a claim; that booklet should be provided with the summary plan description. If you do not have a copy of the summary plan description, or the claims procedures, you can request them in writing from the plan administrator. Any time you send a letter to an ERISA plan administrator, keep a copy for your records. It is also a good idea to send letters by certified mail, return receipt requested, to create a record showing the letter was received.

How do I submit an ERISA disability claim?

The summary plan description, or the claims procedure booklet, must describe how to make a claim under your employer’s specific disability insurance policy, including where to send the claim and the type of information that should be provided. It is important to provide all the information requested and, if possible, to work closely with your doctor to be sure all the necessary information is submitted.

How long before a decision is made?

Claims for disability benefits must be decided not later than 45 days after the plan receives the claim.  The plan administrator is allowed, however, to take up to 60 additional days to review the claim — provided it explains the circumstances requiring the delay.

What if my ERISA disability claim is denied?

If your claim is denied, the insurance company or ERISA plan administrator must explain in writing why it was denied.  It also must advise that you may appeal the claim denial, and describe how to make that appeal. The appeal is not optional – if you do not submit an appeal to the ERISA plan administrator, your will likely lose your right to later challenge the claim denial in court.

How do I appeal an ERISA disability claim denial?

Simply writing a letter asking the plan administrator to change its mind is not enough. A strong appeal may require detailed medical information, letters or certified statements from doctors, and scholarly articles about the disabling condition. A strong appeal may also include letters or reports from specialists who perform physical capacity evaluations, psychiatric or neuropsychological evaluations, or vocational rehabilitation evaluations.  An experienced ERISA attorney can help coordinate and prepare a solid appeal.

How long does the insurer have to decide an appeal?

Claims for disability benefits must be decided not later than 45 days after the plan receives the appeal.  The insurance company or plan administrator is allowed to take up to 45 additional days to review the claim — provided it explains the circumstances requiring the delay.

What if my appeal is denied?

If the plan administrator denies your appeal, the next step is usually to file a lawsuit asking the court to declare that you are entitled to the disability benefits.  ERISA lawsuits are unusual proceedings.  Frequently the court will not consider any evidence or information except the plan administrator’s claims file.  For this reason, it is very important that the appeal be as complete and thorough as possible, because the papers submitted with the appeal become part of the evidence the court will review.

Despite their friendly slogans and engaging advertising, disability insurers are profit-driven institutions that regularly deny claims to increase profits.  They will often not change their decision unless and until they are challenged in court.

About Seattle ERISA lawyer Mel Crawford:

Mel Crawford worked with people with disabilities for eight years before becoming an attorney.  After graduating magna cum laude from Harvard Law School in 1993, Mel’s first trial in Seattle was an ERISA disability claim, and resulted in a full award of disability benefits.  He has been helping people with ERISA disability claims since that time.

Mel helps people with both short-term and long-term disability claims, including people whose claims are based on psychiatric disabilities. He has successfully litigated ERISA disability claims against Prudential, Aetna, Unum, Liberty Mutual, Liberty Life Assurance Company of Boston, MetLife, Hartford, and the Standard Insurance companies, among others. Mel also accepts non-ERISA disability cases.