Understanding ERISA Disability Claims

Person looking over paper to understand ERISA Disability Claims

ERISA is not a form of disability insurance

It is important to realize that ERISA is not a form of disability insurance.

Instead, ERISA is a federal law that will govern how a disability insurer will sign up plan participants, analyze their claims, and award benefits.

In other words, it is a set of rights that employees have guaranteeing that they receive fair treatment in the disability claims process. But you need to have group disability insurance with your employer before you get those rights.

Many complications can arise when an employee submits a request for benefits. Some of the issues include:

  • Whether your injury qualifies as a disability under the plan. Each plan defines disability in its own way, and some plans have fairly strict definitions that will lead to many denials. It is entirely possible to be denied a claim even if you are seriously disabled, all because your particular injury does not fit the plan’s definition of “disability.”
  • Whether the insurer requires that you apply for Social Security Disability Insurance (SSDI). This can save the insurer money, since any money you receive from SSDI is offset against your insurance benefits.
  • The amount of the benefit. Plans typically calculate benefits based on a percentage of the worker’s salary, e.g., 60 percent. So if you make $500 a week, you could get $300 in disability benefits. But questions sometimes arise around how to properly calculate your income.
  • The length of time you receive benefits. Look at your plan. Many plans will set a maximum amount of time, whereas other plans will allow a claimant to receive benefits until they reach a certain age.

Applying For Benefits

The process for applying for benefits will be set out in your insurance plan. Each plan is different, and you need to follow the disability claims process. Often, you need to fill out paperwork and include supporting documentation about your disability.

Typically, an application for benefits will consist of the following:

  • Your application with detailed information about your disability
  • Your employer’s information about your disability
  • Your attending physician’s statement

You submit the claim to the plan’s administrator for consideration. Always keep a copy of everything you submit in the event your application is lost.

Many people unfortunately don’t know how to begin a disability claim. They haven’t kept good medical records and might not even be sure of the technical diagnosis the doctor made.

However, now is the time to get organized. You need to submit your claim in a timely manner, so any delay could only hurt you. Failure to follow the rules for submitting a claim could cause you to lose important appeal rights.

There also must be a description in the Summary Plan Description (SPD) of how you make a claim. This transparency is a critical safeguard afforded by ERISA. If this description of the claims process is missing, then you might be able to hold the plan accountable under ERISA for not following the law.

Contact the Peace Law Firm Today

ERISA Section 503 requires that plans permit someone to help you make a claim. This authorized representative could be someone close to your or an ERISA attorney. So if you need help, do not be afraid to ask for it. Contact us today!