What would you do if you suddenly found yourself unable to work for an extended period of time?  How would you support yourself and your family?  In these situations, there are generally two types of benefits people rely upon (apart from workers’ compensation benefits in the event you are hurt at work), Social Security Disability and ERISA Disability. Let’s look at Social Security Disability and how it can benefit you.

Social Security Disability is available through the Federal Government to all workers who have worked a sufficient amount to qualify and meet medical requirements.  Benefits are available for those of us who have suffered a serious long-term work impairment or disability.  The length of the disability must exceed one year or be expected to last more than one year.  These benefits are also available for the loved ones of a deceased worker in certain circumstances.

Although Social Security Disability Benefits arise out of the time you have worked and paid into the social security system, you are entitled to receive Social Security Disability Benefits whether the disability is the result of some work-related injury or disease, or whether it is the result of some medical condition that is not in any way related to your employment.  For purposes of Social Security Disability Benefits, a qualifying disability is a qualifying disability regardless of whether it in any way stems from your work activities.

If your initial application for Social Security Disability Benefits is denied, you will receive a written notice from the Social Security Administration.  The first level of “appeal” is called “Reconsideration.”  If your initial application is denied, you must submit your request for Reconsideration within sixty (60) days of when you receive the denial.  This stage again involves a review of the record by an employee of the Social Security Administration, similar to the initial review of your application.  If you then receive a denial at the Reconsideration stage, your next “appeal” is to request a hearing in front of an Administrative Law Judge (“ALJ”) with the Social Security Administration.  Again, you have only sixty (60) days from when you receive the denial of your Request for Reconsideration to request a hearing in front of an ALJ.  At the hearing before an Administrative Law Judge, you will be able to argue, present your evidence, and provide testimony to the ALJ in support of your claim for Social Security Disability Benefits.

Of those who apply for Social Security Disability, approximately three out of four applicants are initially denied, yet approximately seventy percent (70%) of those who appeal are successful.  It is therefore important to have a qualified, experienced Social Security Disability Attorney on your side.

ERISA Disability Benefits or Employee Retirement Income Security Act Benefits are governed by Federal Laws.  ERISA was enacted on Labor Day in 1974 to protect workers from pension plans going bankrupt.  Later, ERISA was broadened to apply to long term disability plans provided for workers by employers.  ERISA Laws are vast and complicated.

ERISA was meant to protect workers, but insurance companies have lobbied Congress for almost forty (40) years and now the law in many ways favors these big Insurance companies.  ERISA cases are heard by Federal judges and have a standard of proof of “abuse of discretion.”  This is a very high standard to prove, and it means you must prove not merely that there is evidence that could support a decision granting your long term disability claim, but instead that the insurance company actually “abused its discretion” when it decided to deny your deserved disability benefits.

Long Term Disability Insurance Policies are written to replace income of workers who become disabled due to injury, physical illness or mental illness.  Each Long Term Disability Insurance Policy will have these terms defined within them.  While the replacement of income is the purpose, this is not the outcome entirely.  Most Long Term Disability Insurance Policies pay sixty to eighty percent (60-80%) of the policyholder’s pre-disability earnings.  Most Long Term Disability Insurance Policies begin to pay only after six (6) months of disability.  They normally pay until the policyholder reaches a certain age, or until they are able to draw Social Security Retirement Benefits.  The age at which payments stop depends totally on the terms of the individual policy.

If you or a loved one is denied coverage under your Long Term Disability Insurance Policies or Plan you must act to protect your rights.  ERISA requires one or more administrative appeals.  These appeals are usually within the Insurance Company and ERISA Laws allow the Insurance Company to interpret their own policy language.   During this Administrative Appeal it is very important to enter evidence into your file because your ERISA Disability Benefits Appeal will be based on the evidence contained in your claim file.  It is at this point that you must submit records from your current treating medical providers or psychiatrist that specifies your diagnosis and prognosis.  This evidence or support should include your symptoms and all limitations you may have.  It is also important that the information supplied by your treating medical and/or psychological providers track and answer specific issues that must be addressed in the interpretation of your ERISA Long Term Disability Insurance Policy.

Evidence to support your ERISA Disability Benefits Appeal includes, but in no way is limited to, an Independent Medical Evaluation (IME), Functional Capacity Evaluation (FCE), MRI, CT Scan, EEG, EKG or other testing that may help substantiate your disability and satisfy any policy requirement for “objective findings” of your Long Term Disability.

Because of the “abuse of discretion” standard to be used by the Federal Court Judge, an ERISA Disability Benefits Appeal  can involve a very tough standard to meet. To sustain a denial, insurers usually only need some evidence to support its position. However, sometimes insurers deny for the wrong reasons or apply the wrong legal standard.  Retaining an ERISA Long Term Disability Benefit attorney soon after your denial can be an important step for overcoming this difficult standard and preparing the record in case it must be taken beyond the administrative appeal(s) required by your policy and into Federal Court.