FAQ: When should I get an attorney involved in my disability/life insurance/pension issue?

                There are three common times when you should think about involving an attorney in your ERISA employee benefits dispute or claim: (1) when submitting an application for benefits, (2) after the denial of benefits, and (3) at the commencement of litigation. Here is why you might choose to retain an attorney at any one of these times.

                You might decide to hire an attorney to submit your application or claim for benefits. This is a good strategy if you have a complicated situation or issue that may affect your application. One example might be if you are applying for long-term disability benefits after being terminated from employment or quitting from your job. Another example might be if your disabling condition is complicated your application for disability benefits may require some explanation as to why you can no longer perform you job. Applications are time consuming and complicated, so sometimes people hire an attorney to handle the application because he or she does not have the time or energy to devote to making sure the insurer receives all the information necessary. As long as your benefit plan is governed by ERISA, you will be allowed a chance to appeal any decision made by the plan administrator that is adverse to you, so many claimants choose to apply for benefits on their own and then hire an attorney only if they are denied.

                The most common time individuals hire an attorney is after he or she has had a pension, life insurance, or disability benefit denied. The attorney can then submit an administrative appeal for the claimant. An administrative appeal is a written appeal to the plan administrator explaining why the decision to deny benefits was wrong, and submitting any new evidence in support of the claim. An administrative appeal is VERY important, because once it is submitted you are frequently no longer allowed to submit any new evidence to support your claim to the insurer. Generally, it is best to consult an attorney when submitting your administrative appeal, so you can be sure the evidence in the administrative record (everything submitted to the plan administrator by you, and everything the plan administrator gathers or creates on its own in regards to your claim) is as complete as possible so the insurer can make a full and fair review of your claim for benefits.

                Once you have completed all your administrative appeals, the only option to pursue your case further is usually to bring a lawsuit in federal court. At this phase, you should almost always hire an attorney to represent you in your case. ERISA cases have complex legal issues like how much deference should be given to the insurer’s decision. It is best to have good legal representation once litigation begins.

What to Do If Your Disability Benefits Are Terminated

“Your Disability Benefits Have Been Terminated.”

            Working with insurance companies to maintain disability benefits is difficult. Even after your benefit claim is approved, which is a feat in itself, the insurance company usually has the right to request that: (1) your physician submits documentation of your progress and your expected return to work; (2) you provide updated medical records from all of your doctors; (3) you submit to an examination with one of the insurer’s own physicians; or (4) that you answer lengthy questionnaires about your activities, medical condition and financial records.

We set out below some ideas of what you should do if the insurance company for your employer-provided disability benefit plan sends you a letter letting you know your disability benefits are being terminated.  But, importantly, there are attorneys (like us at the Law Office of Katherine MacKinnon) that specialize in helping people when they receive the dreaded, “your benefits are being terminated” letter.

“What Should I Do Now?”

1.      Read the letter carefully. Read the letter the insurer sends to you explaining why it is denying or terminating benefits. What are the insurer’s reasons for denying the benefits? What does the letter say the procedure is for appealing that decision?   

2.      Make note of any due dates. A letter explaining that a company is denying or terminating benefits must outline the process which you must follow to appeal the decision. The letter should also tell you the date by which any action must be taken – be careful not to wait until the last minute to either contact an attorney for help, or begin working on an appeal yourself.  The appeal is often a big undertaking.

3.      Is the insurance company asking for something? While carefully reading the letter, notice if the company is asking for any information that was not submitted. Are benefits being terminated or just suspended for failing to have a doctor submit a form? Is paperwork missing? Maybe there is something simple the company is simply missing or asking you to complete that would fix the whole problem.

4.      Write to the insurance company, and request copies of all your plan documents and a copy of your claim file. The company is required by federal regulations to provide you with “reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits.”  29 C.F.R. §2560.503-1(h)(2)(iii). Since there is a time limit on when an appeal can be submitted or a claim can be brought in court, it is important to write and ask for these documents right away.  

5.      Administrative appeal. In some circumstances a person can put together their own appeal, and in some circumstances it is best to consult an attorney. An appeal is often your best and last opportunity to furnish the insurer with all relevant information regarding your disability benefit entitlement.  The insurer needs and wants the information so that it can make an informed decision about whether you are entitled to benefits. Helpful information might include: all your medical records from each provider; a statement explaining your disability and how it affects your ability to work; letters from your doctors, coworkers, family members, or friends talking about your disability and inability to work; a videotape showing your condition and how it impacts you; your employment records showing how you struggled to work; any decisions from the Social Security Administration, other disability insurers, or other entities that considered you to be disabled.

Putting together an administrative appeal is a huge project, involving collection of many pieces of information from multiple sources. If you get confused or frustrated, you can always contact an attorney who specializes in ERISA benefits for help. Good luck!