Preexisting Condition Clauses in Long Term Disability Plans

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Preexisting condition exclusion provisions in group short and long term disability plans are quite different from preexisting conditions as we typically understand them. Those with potentially disabling conditions may still be able to secure their income through disability insurance, depending on the preexisting condition exclusion contained in the plan. Here is a typical preexisting condition exclusion as it appears in … Read More

Looking to Win a Disability Insurance Claim? Start here.

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Many of the leading disability insurance companies have engaged in systematic strategies to deny valid applications (“claims”) by policyholders for disability benefits.1 Aided by a federal law known as ERISA, (Employee Retirement Income Security Act of 1974), they have been given procedural advantages and have means at their disposal to intimidate and oppress even the most well-informed “claimants” seeking ERISA … Read More

The ERISA Playing Field Usually Favors the Insurer

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Most ERISA long term disability plans contain a clause granting the plan administrator discretionary authority to determine eligibility for benefits and to construe the terms of the plan. This is known as a “discretionary clause.” If a plan contains a discretionary clause, a claimant who was denied benefits cannot go to court and argue that he or she is in … Read More

ERISA Plans Offset Other Benefits

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ERISA plans offset other benefits, like SSDI benefits and workers’ compensation benefits, which can cause very unfortunate results for unweary claimants.  An ERISA disability benefit plan is a contract, written by an insurer and chosen by an employer to offer as a benefit to employees. Employees who join the plan have entered into a contract. Insurers write into that contract … Read More

How ERISA Administrators Weigh Social Security Approvals

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Most group long term disability plans require claimants to apply for social security disability benefits. In fact, administrators often offer to assist claimants by referring them to a company that will represent them. They do this because SSDI benefits are typically included as a ‘deductible source of income’ under most plans, meaning that administrators can reduce the amount of any … Read More

Insurer Reimbursement Rights in ERISA LTD Plans

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In “ERISA Offsets Other Benefits” we explained how a claimant suing for disability benefits can end up losing and then owing money back to the insurer.  In that example, the plaintiff sues seeking payment of her disability benefits and loses, and the ERISA disability payer countersues to collect money from the plaintiff’s retroactive social security disability check that is owed … Read More

No Ordinary Discovery in ERISA Disability Litigation

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The first thing to understand about the topsy-turvy world of ERISA disability benefits litigation is that the plaintiff has no right to take ordinary discovery after filing a complaint in federal district court. On its face, an ERISA disability case looks like a contract dispute between the parties: the claimant has sought benefits pursuant to the disability plan and the … Read More

Initial Applications for ERISA long term disability Benefits

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Plan administrators have the authority under the ERISA statute to review initial ERISA long term disability claims and to deny claims. There is typically a procedure for submitting an initial claim that requires applicants to obtain attending physician reports from health care providers, fill out activities of daily living forms, sign authorizations so that the administrator can gather documents and … Read More

Appeal Denials and Federal Litigation

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An administrator must give notice of its decision on the appeal, setting forth the basis for a denial, again with 45 days, or 45 plus 30 if necessary for reasons beyond its control. Once the administrator makes a final determination and the claimant has ‘exhausted’ all remedies available under the policy, the claimant can bring an action in federal court … Read More