BRYANT LEGAL GROUP
Chicago ERISA Benefits Lawyer
If you receive disability benefits through your employer, chances are those benefits are governed by the federal Employee Retirement Income Security Act, commonly known as ERISA.
ERISA law establishes certain requirements that your employer (the plan sponsor) and insurance company must follow. But unfortunately, it also imposes many legal restrictions, obligations, and delays on disability claimants.
The attorneys at Bryant Legal Group are experienced in assisting clients with short-term and long-term disability claims. Short-term disability plans may be structured as payroll practices governed by state law or as ERISA plans. Most private employer long-term disability plans, however, qualify as ERISA plans. We know the nuances of the law and how ERISA rules can impact your ability to obtain the benefits you need. Whether you need help filing a claim or appealing an unfair denial, give us a call.
Contact us today to schedule a consultation.
I can’t thank David and Jennifer enough for going the extra mile to get Guardian to pay my claim, regardless of the fact that my type of claim, although very legitimate, was difficult to gain coverage. They are my heroes for not giving up. I’m very thankful for both of them and their staff.
What Is ERISA and How Does It Impact My Insurance Claims?
ERISA became federal law in 1974 as a reaction to years of mismanagement and financial abuse in employee benefit plans by plan administrators and insurance companies.
Initially, ERISA was meant to protect plan participants and insurance policyholders from the wrongful conduct of those in control of the plan assets. It established conflict-of-interest laws and various fiduciary duties to give those whose plan assets were diminished (say, in employer-sponsored pension plans) the opportunity to litigate against the defendant responsible for the losses.
ERISA has evolved into a comprehensive regulatory framework covering all employer-sponsored benefit plans. Even denial of disability benefits come under the purview of ERISA. In fact, federal ERISA regulations preempt state regulations in many situations, which can substantially change your legal options and strategies.
Does ERISA Apply to My Disability Insurance Plan?
ERISA coverage applies to welfare benefit plans (including disability insurance, health insurance, life insurance, dental, vision, severance benefits, and retirement plans) provided through almost all private employers.
There are two primary exemptions to ERISA coverage. Your employee benefits plans will not be subject to ERISA rules and regulations if:
- Your employer is a qualified religious organization
- Your employer is a public entity, such as a government agency
Individual disability insurance policies or health insurance coverage that you purchased on your own, rather than through your employer, however, are not governed by ERISA.
Quick Pros and Cons of ERISA Coverage
Again, while ERISA law does offer some important protections for policyholders, there are also several drawbacks when compared to non-ERISA plans.
On the plus side:
- ERISA prohibits employers from retaliating against employees who make a benefits claim (or who exercise their rights in challenging or litigating the denial of a claim).
- ERISA requires that plan administrators provide all plan documents to policyholders who request such information.
- ERISA requires the insurance company provide the rationale for why a benefits claim was denied, all documents that were used to make the determination, and the procedure for filing an appeal.
- ERISA imposes various duties on plan fiduciaries such as the plan administrator, and it gives policyholders the right to sue and recover damages for losses related to the violation of fiduciary duty.
However, there are several ways ERISA can make it harder for claimants to get the benefits they deserve:
- ERISA policyholders must exhaust all their administrative appeal options before filing a lawsuit against the insurance company. This is often a complex, frustrating, and time-consuming process.
- The deadline to file an appeal is only 180 days. This isn’t very much time, particularly if you are dealing with a complex medical issue.
- If you do file a lawsuit, depending on the circuit where the matter is filed, the court may be limited to a review of the insurance company’s claim file. You often cannot add new evidence in support of your claim or in response to the insurance company’s evidence that purportedly supports its decision to deny or terminate benefits.
- Damages for bad faith, which may include punitive damages, are not available to policyholders in ERISA-governed benefit claims.
Looking for Personalized Advice From an Insurance Lawyer?
How Our Chicago ERISA Lawyers Can Protect Your Rights
If you are ready to file a disability claim or have been denied benefits under an ERISA policy, Bryant Legal Group can help. When you work with us, an ERISA disability attorney in Chicago will immediately request a complete copy of your benefit plan.
We are very familiar with the complex language used in these types of plans and will thoroughly review documents to determine the rights and benefits you are owed. Our team will also assist you with the filing of your disability claim and take swift action to appeal any unfair or unreasonable decisions associated with your claim.
At Bryant Legal Group, an experienced Chicago ERISA attorney can assist you in several different ways as you navigate the complexities of your ERISA-governed insurance benefits dispute.
Developing a Comprehensive Insurance Claim File
Developing a comprehensive claim file containing all evidence supporting your disability claim is crucial to the success of your ERISA benefits dispute. Relevant evidence might include:
- Medical records
- Expert reports
- Research reports
- Claim-related communication
- Vocational and functional evaluations
- Personal testimony
- Photographic and video evidence
- Letters of support (from your physician and other healthcare providers)
Remember: even if you end up filing a lawsuit, the court will only be able to review evidence that is already in the claim file. As such, you’ll want to make sure your claim file is as complete as possible.
- Related Article: Do You Know the Deadline for Filing Your ERISA Claim?
Identifying and Litigating Related Employment Conflicts
ERISA prohibits retaliation by an employer against their employee for trying to obtain an insurance benefit. For example, if you submit a claim for disability benefits under your ERISA plan, your employer cannot put you on a damaging alternative career track (i.e., an adverse action) to punish you for simply exercising your rights.
The attorneys at Bryant Legal Group have experience identifying employment-related issues that arise from ERISA disputes and assist clients in such circumstances, including ERISA litigation.
Objecting to Untenable Provisions in Your ERISA Plan
If you have been on the receiving end of a denied ERISA disability claim, a Chicago attorney may be worth contacting for further guidance. Skilled attorneys can identify clauses in your insurance policy that are unenforceable based on applicable law, and your lawyer can advocate aggressively on your behalf to secure the rights that were impeded by the insurer.
Going Through the Administrative Appeals Process
ERISA requires that welfare benefits plan participants, including those who are disability benefits plan participants, first exhaust their administrative appeals before they can pursue civil litigation.
Each plan and insurer have their own administrative appeals procedure, but they are usually complicated. While the insurance company is required by law to inform you about the basics of filing an appeal, they are not going to give you any useful advice about how to build a successful case. They have no incentive to do so and, in most instances, the applicable insurance policy puts the responsibility for proving a disability claim on you, the insured.
Working with a Chicago ERISA disability lawyer gives you the best chance of filing a successful appeal. Depending on the strength of the evidence and legal arguments submitted to support the claim, the insurer may choose to award benefits and avoid the messiness of civil litigation.
Handling ERISA Benefits Litigation
If all your administrative appeals are unsuccessful, you have the option of filing a lawsuit and taking your case to federal court. Our attorneys work closely with our clients to evaluate whether is the appropriate way to try to resolve the matter or if pre-litigation negotiation with the insurance company might work.
Throughout the legal process, your ERISA attorney may continue to negotiate with the insurance company to reach a settlement. This approach provides a dual pathway: pursuing judicial remedies while exploring potential negotiated outcomes.
- Related Article: What Does It Mean to Exhaust Your ERISA Administrative Remedies?
Our Settlements and Verdicts
After our client’s disability insurance benefits were improperly terminated, we negotiated a $1.6 million settlement for him.
Our medical practice team recovered $500,000 for a physician group when an insurer failed to properly reimburse them for their services.
We collected $440,000 in unpaid disability insurance benefits for our client and got her LTD benefits reinstated by proving she was disabled from any occupation.
Consult a Skilled Chicago ERISA Long Term Disability Lawyer to Discuss Your Benefits
Here at Bryant Legal Group, P.C., our team of attorneys boasts decades of experience representing the interests of policyholder-clients in disputes with their insurers (and with plan administrators). We handle both ERISA and non-ERISA insurance claims and, as such, are well-equipped to understand the unique challenges of ERISA litigation.
We are committed to results-oriented legal advocacy. Throughout our firm’s history, we have found that the key to securing a successful resolution in an ERISA dispute is in developing a personalized case strategy. We work closely with our clients throughout the dispute process to ensure our goals are aligned and that we have the information needed to effectively navigate such litigation.
We consistently negotiate favorable settlements and secure favorable verdicts (in administrative appeals and at trial) on behalf of our clients. Over the years, we have secured millions of dollars of benefits in a range of insurance disputes including those that involve ERISA-covered benefits plans.
Interested in learning more about your claim and how best to proceed with resolving your ERISA dispute? Call us today at (312) 561-3010 or submit an online form through our website to connect to an experienced Chicago ERISA long term disability lawyer at Bryant Legal Group, P.C. We look forward to working with you.
The content provided here is for informational purposes only and should not be construed as legal advice on any subject.
Frequently Asked Questions
- Evaluating their coverage and identifying possible issues with the policy’s language before they need to file a claim
- Guiding clients through the disability insurance application process
- Negotiating with the insurance companies
- Filing appeals with the insurer, state, or federal court
As soon as you have a question or concern about a claim, reach out. Often, you only have one chance (and a limited amount of time) to appeal a denied claim. The earlier you seek legal advice, the better.
It’s critical that you do not forgo such notification, or you could not only lose your benefits, but you could also be held liable for damages.
Common justifications for a claim denial include:
- Lapse of coverage
- Material misrepresentations in the original insurance application
- Insufficient evidence of disability
- Application of a coverage exclusion
- Disability is tied to a pre-existing condition
- Failure to seek ongoing medical treatment
Specialty Specific Own-Occupation
If your insurance policy includes a specialty specific own-occupation definition of disability, then you will be entitled to benefits if you can prove that your condition renders you incapable of substantially performing the primary duties of your own occupation in the specialty in which you perform it.
For example, suppose you work as a trial attorney, but you experienced a cognitive disability. If you are unable to meet your profession’s cognitive demands, you should be entitled to benefits under the policy.
Own-Occupation
If your insurance policy includes an own-occupation definition of disability, then you must prove that your condition renders you incapable of substantially performing the primary duties of your current occupation.
For example, suppose you work as a financial analyst. Because of a disability, you cannot remain on task for more than 10 minutes at a time and are incapable of performing the complex, hours-long analyses necessary for you to perform your job as a financial analyst. In this case, you might qualify for own-occupation disability even if you can still do other, simpler work.
Sometimes, insurers deny benefits in the own-occupation context by arguing that the duties of your current occupation can be different, and that the duties of your current occupation are not indicative of the “norm” in the industry. If you experience this kind of pushback, consult with a lawyer immediately.
Any-Occupation
If your insurance policy includes an any-occupation definition of disability, then you must prove that your condition renders you incapable of substantially performing the primary duties of any other job for which you are reasonably qualified. This is an extremely strict definition of disability and often requires a nuanced approach to overcome.
ERISA was created with the intention of protecting plan participants from the abuses of plan administrators, but over time, ERISA has actually developed into something of a headache for the plan participants it was originally meant to protect. If your plan is ERISA-governed, for example, then you must fully exhaust your administrative remedies before pursuing civil action against the plan administrator or insurer — this can extend the timeline of the dispute and keep you in a vulnerable position for longer.
Additionally, ERISA preempts bad faith actions against insurers, thus eliminating a significant recovery option for insured plan participants whose insurers have mishandled their disability claims.
- When such a situation occurs, the plan participants have a right to sue and recover damages for their losses.
- Typically, this is accomplished through a class action, as there are many others in the “class” of plaintiffs who are similarly affected by the fiduciary violation.
- For example, suppose that the administrator of your ERISA-covered retirement fund mismanages the funds through extremely risky investments. The losses are so substantial that the plan can no longer pay out the benefits to which you’re entitled. You would almost certainly have a claim against the fiduciary.
ERISA is a federal law that pre-empts state bad faith laws, including those of Illinois. If your disability benefits claim has been mishandled by the insurer, and ERISA applies, then you will not be entitled to bring a claim for bad faith. This can undercut your ability to obtain maximum damages in extreme cases, as bad faith claims often lead to significant damages (and sometimes, courts award punitive damages, which can further multiply the amount received).
In some limited cases, however, you may be able to bring a separate fraud claim against certain defendants. You’ll want to consult a qualified ERISA disability attorney in Chicago for an evaluation of your bad faith claims and how you might be able to strategize around the pre-emption issue.
Many common law fraud claims are pre-empted by ERISA as well — such a claim might only avoid pre-emption if you can show that the defendant owed you (and violated) a duty independent of the ERISA-covered plan.
- The administrative appeal process is a pre-litigation, internal (directly with the insurance company) review procedure that is imposed on benefits claimants under ERISA.
- It is not necessarily a simple, efficient or quick process — in fact, in some cases the administrative appeal can take from six months to a year to complete.
- You have just 180 days to submit a request for review pursuant to the administrative appeal process.
- If you are dealing with a denied ERISA disability claim, contact a qualified Chicago attorney for help with the administrative appeal process. Attorney guidance is critical, even at this stage, as a favorable resolution to the dispute may be possible.
Every plan is different and may impose different procedures. For example, some plans may extend or contract the typical deadlines. Others may have different factors for determining the person who will be reviewing the claim denial.
During the administrative appeal process, you will send comments and evidence that supports your argument that the claim should have been accepted and benefits awarded. In doing so, you will have to evaluate the plan documents, as well as other relevant documentation — such as medical records, file physician review reports, and vocational opinions. Once a decision has been made (regarding your appeal), you will receive a written decision that describes the specific reasoning on which the denial (or acceptance) is based.
At this point, if the administrative appeal process has led to a denial (in whole or in part), you will have exhausted all available remedies and will be entitled to bring a civil action against the defendants.
Although ERISA benefits claims can be brought in many courts against both the insurer and the plan administrator (your employer)
- By pursuing an ERISA benefits claim, you are not jeopardizing your employment.
- In fact, ERISA regulations prohibit employers from retaliating against their employees for attempting to pursue a claim under ERISA, or for otherwise exercising their ERISA-based rights.
- For example, if you appeal the denial of your disability benefits and then later bring an action against the insurer for damages, your employer cannot take an adverse employment action against you (i.e., termination, refusing to give a promotion or a raise, etc.) on that basis.
- For short term disability benefits, we have seen periods as short as 7 days from the start of disability and, for long term disability benefits, we frequently see time limits of 30 days.
- After your claim has been denied, ERISA regulation gives you 180 days to file an appeal. If the appeal is denied in whole or in part, you have a right to bring an action against the insurer and pursue the claim in a court of law. There are deadlines for this, too, however.
- ERISA statute of limitations rules are somewhat complicated. As a general rule, most ERISA-covered plans simply use the applicable state jurisdiction’s statute of limitations for written contracts — for example, in Illinois, most ERISA-covered plans will give you a 10-year deadline that runs from the date of formal denial (of benefits).
- Importantly, however, alternative deadlines may be set by each plan, and as such, the deadlines can vary substantially. ERISA only requires that the deadline be reasonable, given the circumstances.
For example, a 90-day deadline for bringing an action against the insurer would likely be considered unreasonable, whereas a two-year deadline would likely be considered reasonable.
Given the variable nature of such deadlines under ERISA and the fact that your claim may be abandoned if you do not bring an action in a timely manner, it’s critical that you consult with an attorney at an experienced Chicago ERISA law firm for guidance — your attorney will ensure that your claims are brought in a timely manner.
Related Articles
Contact Bryant Legal Group
Get the answers and insight you deserve. Our experienced disability insurance lawyers can evaluate your claim and help you understand all your legal options.