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Private Disability/ERISA

These benefits can be claimed by private policy owners or employees with employer-provided disability insurance.  Policy holders may be entitled to some benefits even if they are able to work on a limited basis.


Types of Common Long Term Disability Policies


Group Welfare Benefit Plans

Group Welfare Benefit Plans are provided by an employer to its employees. 


They are governed by federal law under the Employee Retirement and Income Securities Act, commonly known as ERISA.


The premiums are usually fully or partially paid by the employer.


Such policies are frequently administered by an insurance company that makes claim determinations and pays benefits under the plan. In some cases, the bnefits are paid by the employer.



Under ERISA policies, claimants are afforded certain rights and protections: 


A claims administratior of an ERISA policy has a fiduciary duty to a claimant to act in his or her best interests. In the event that a claim is denied, there are strict guidelines as to the information that must be provided to the claimant including a written decision that sets forth the reason for the denial, the informatin that was relied on in making the determination, and notice of the claimant's right to appeal. 


The appeal notice must, among other things, state the time limit in which to file an appeal (180 days under ERISA), advise the claimant of his or her right to receive a comlete copy of the Plan, and the insurer/administrator's files in connection with the claim.


Other policy terms vary widely but usually have some basic similarities.



Private Policies/Income Replacement Policies


These policies are purchased from an insurance company and paid for by an individual.  


They are frequently purchased by professionals such as doctors and dentists and those who are self-employed.


These policies are not governed by ERISA. The provisions can be similar, but vary widely. 


They can be more advantageous to a claimant, but may not necessarily so. 


In the event that a claimant seeks to appeal a denial of his or her claim, he or she will not necessarily be provided with the claim file or receive other information that would be mandated under an ERISA policy. 



How Can A Lawyer Help?

Before you file an application:


At the initial application phase an attorney will help the claimant navigate the application process. 


The attorney may assist with the completion of forms and advise the claimant as to the information to provide in support of the claim. The attorney will make sure that the claim file is fully developed in the event that the claim is denied and an appeal becomes necessary. 


In some cases, when an insurer requests an interview with the claimant, an attorney will be present to assure that the claimant’s rights are protected. 


The attorney can also simplify the process by representing the client on a concurrent application for SSD benefits.




When your claim has been denied or your benefits have been terminated:


For someone who has already had their claim denied, or who has been receiving benefits and then been terminated, an attorney will handle the complicated appeal process. The attorney who has experience in dealing with insurance companies on these matters and, among other things, the interpretation of medical facts, evidence of administrator misconduct, and proper application of plan terms will use that expertise to review the entire claim history.



Do I need to qualify for Social Security Disability in order to get private Long Term Disability benefits?



The considerations are different for SSD and LTD claims. 


Individuals may be eligible for Long Term Disabilty benefits even if they do not meet the requirements for Social Security Disability. 

Whether a claim is made under an ERISA policy or a private policy, every case depends on development of  the medical and vocational facts, and the specific terms of the policy.

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