What Is an ERISA Dispute?

After the Employee Retirement Income Security Act of 1974 (ERISA) was enacted, federal law began regulating retirement plans and insurance for private employers in the United States.

The Act established legal guidelines for all private pension plans, investment practices, and the administration of these programs. Minimum standards regarding life insurance, disability, welfare, and health plans were established to protect individuals under these plans.

What Is ERISA Litigation?

ERISA was originally signed into law by President Gerald Ford. The Act initially came after issues related to pension plans, especially after the Studebaker Motor Company filed for bankruptcy and left company workers without funds and remedies for their lost pension plans.

For the last 35 years, ERISA has gone through more than forty amendments, with most of the changes occurring in the pension portion of the Act.

Modifications in 1985 and 1996 were the most notable and included the Consolidated Omnibus Budget Reconciliation Act and the Health Insurance Portability and Accountability Act.

The Department of Labor (DOL) oversees the Act; however, the law only applies to private employers or those not affiliated with the government. If a worker has a denied appeal and he or she has followed all guidelines established by ERISA, the next step could be to file a lawsuit against the employer.

ERISA allows a judge to review the case for possible abuse of discretion. The judge can examine and overturn the decision, but the judge’s authority is limited.

The Complexities of the ERISA Rules

ERISA is a very complex Act, and it is continuously changing to meet the demands of today’s worker. Regulations vary, and therefore, this area of the law is often too complicated for a layperson.

ERISA has a manual for employees and enforcement-related guidelines, but it is not designed to help you interpret the Act. For an employer to be guilty of civil violations of ERISA, the following elements must be present:

  • Failure to Execute an Employee-Favored Plan – The company fails to operate the benefit plan with prudence and in the interest of the employees.
  • Asset Usage and Benefits – Under ERISA, employers have the right to use benefits for certain parties, but cannot solely do so to help the plan sponsor, parties related to the individuals, or the program’s administrator.
  • Valuing Assets – Employers cannot improperly value assets or ignore current fair market values. Also, assets cannot be held in a trust.
  • Failure to Monitor – Employers must monitor and carefully select all service providers related to their plan. Inability to do so is a violation of ERISA.
  • Adverse Actions Against Employees – A company cannot take any actions against an employee for exercising their rights under the plan, including terminating, fines, or discriminating against workers.

When Is an ERISA Claim Necessary?

There are two types of claims filed under ERISA: a benefit claim and a breach of fiduciary duty claim.

  • Benefit claims include the following:
  • Health insurance policies
  • Disability insurance and payment coverage
  • Life insurance
  • COBRA policies
  • Vacation benefits

Fiduciary breach claims focus on the actions of those running the plan. If the person does not follow instructions, misrepresents facts to participants or fails to make prudent investments, they could be in violation of their fiduciary duty.

ERISA Limits Damages

Even if you have an ERISA claim, know that the Act limits your damages. You can request the benefits you have lost and interest in past due benefits, but you will not receive pain and suffering or other non-economic damages. Some judges will allow attorney’s fees and the costs of starting and litigating your lawsuit. However, you will not be compensated for administrative remedies and the time spent on those resources.

If you have been denied valid benefits from your employer, or you feel that your employer has breached their duty to you as an employee, you can speak with an attorney that practices ERISA claims. Attorney Ethan Vessels can assist you with your ERISA case.

Schedule a no-obligation consultation at 740-374-5346.

Tips on Long-Term Disability Claims & ERISA

Tips on Long-Term Disability Claims & ERISA

Life can be unpredictable. Many of us find comfort in having backup plans and safety nets for our lives. People open a savings account for unexpected expenses, families own two vehicles should one break down, and many employees carry long-term disability (LTD) insurance through their employer in case they get hurt and are unable to work.

Employer-provided LTD policies are governed by a federal law known as ERISA, the Employee Retirement Income Security Act. LTD applications are reviewed by a claim administrator, and these claim administrators work for the insurance company. There is an obvious conflict of interest, and therefore, claims are often denied. Claim administrators may feel pressured to deny claims, even deserving ones, so the insurance company they work for saves money. Getting an LTD claim approved is a complicated process. Here are some common reasons for these claims being denied, as well as mistakes to avoid during the process.

Missing the deadline.

Most employer-provided insurance plans give 180 days to appeal an initial denial. Look for the deadline on the notice of denial. It is recommended to use this time frame to talk to an LTD attorney who can gather evidence and complete the required documents. The evidence and documents are submitted to the insurance company and are contained in the “administrative record” for your case.

The administrative record is something that must be requested from the insurance company. This record has all the information about why your claim was denied, as well as the medical reports from doctors. Knowing exactly why your claim was denied will help your attorney know how to defend you.

Additionally, if your claim goes through all the administrative appeal channels without being approved, the claim could go all the way to federal court. Only the information in the administrative record is what will be considered when deciding your case. This is part of ERISA law. You can not wait until court to present records and/or provider statements, as they will not be taken into account. They must be added to the administrative record first.

Providing inadequate medical evidence.

When involved in an LTD claim, you must go to regular medical appointments. The insurance company expects you to make the necessary visits to your doctor or specialists. You should not miss any appointments, or it could be used against you as evidence that you are not disabled.

Your claim could be denied because the insurance company does not have the appropriate medical records. Though it may be the insurance company’s fault for not requesting them, you or your attorney will need to follow up and ask for the records they, and then double check to make sure no records are missing.

One of the most crucial elements in proving your disability is your doctor’s opinion and statement. If your doctor is willing to write a detailed letter supporting your disability and stating what your limitations are, it will go a long way in helping to win your claim.

It is also important to get reports from experts, which could include a functional capacity evaluation report and a vocational expert report. A functional capacity report is an objective test performed by a physical therapist. You will be tested for various job-related tasks like sitting, standing, pushing, pulling, and lifting. A vocational expert is someone who knows about availability in the job market and what skills are needed to perform specific jobs. Your insurance company will likely have their own vocational expert write a report, which will likely lean in favor of the insurance company. You or your attorney may need to find a vocational expert of your own to help with your claim.

Failure to meet the policy’s definition of disabled.

Be sure to check your LTD policy summary and find its definition of disability. It will typically define disability one of two ways. It will either define disability as being medically unable to carry out the duties of your “own occupation,” or  as the inability to perform the duties of “any occupation.” There is a big difference between the two. If you are an injured construction worker applying for LTD, and your policy defines disability under the description of “any occupation,” then you may still be expected to go out and find a job.

Your insurance company is allowed to ask investigators to follow you and take video surveillance. If they record you doing anything a disabled person should not be able to, your claim could get denied, or if you are already receiving benefits, they could be canceled.

For example, if you suffer from chronic back pain, you likely have good days and bad days. Most likely, your good days aren’t pain-free, but you may have enough energy to go out and try to do light gardening or landscaping around your house. If the investigator should catch you on this good day and take footage of you performing this work, it might be enough to justify a denial. The best advice is to simply follow your doctor’s restrictions at all times.  

Talk with a long-term disability attorney.

If your initial long-term disability application has been denied, consult with an attorney, as that is the best way to increase your chance of obtaining approval. A long-term disability lawyer, such as Ethan Vessels, is familiar with the rules and know how the insurance companies operate.

Often, when people try to handle the appeals process on their own, important information can get left out of the appeal. This really plays to the advantage of the insurance company. As stated earlier, if evidence is not submitted in the administrative record during the internal appeals process, it cannot be used later in court.

Contact Fields, Dehmlow & Vessels, LLC to speak with Ethan Vessels, an experienced long-term disability attorney. Call us at 740-374-5346 or fill out our online contact form.

What Is ERISA?

ERISA stands for Employment Retirement Income Security Act. In this video, Attorney Ethan Vessels, ERISA Attorney in Marietta, Ohio, explains some of the complexities and solutions with ERISA cases.

Here at Fields, Dehmlow & Vessels, we handle ERISA claims for employees and plan participants. The ERISA laws govern most employee benefit actions including health plan claims, long-term disability insurance claims, pensions, and even life insurance that is sponsored by employers, accidental death, and dismemberment insurance claims.