Let’s say you have made a claim for long- or short-term disability insurance benefits under your employee plan.
Your claim is based on an illness or injury that prevents you from performing your job’s material duties. You have too much pain to function normally, or perhaps fatigue deprives you from going a full eight hours without sleeping, let alone functioning.
However, although you have been officially diagnosed with an illness or injury, and you cannot work, the insurance company or your ERISA plan administrator has determined you do not meet the definition of disabled under the policy. What do you do next?
Federal law requires every ERISA policy to have an internal appeal process. This procedure allows a plan beneficiary to appeal the plan administrator’s decision to deny long- or short-term disability insurance benefits and cure any defects in the application to secure those benefits. This appeal process matters because it is a chance to get benefits without bringing a lawsuit, and what happens during the appeal will define what a court can consider if suit is brought.
Denial of Long- or Short-Term Disability Benefits: Restrictions and Limitations
The most common reason an insurance company or a plan administrator denies benefits is that no physician has prescribed restrictions and limitations that keep the beneficiary out of work or the restrictions and limitations are not supported by the medical evidence.
Restrictions and limitations are limits of functional capacity that an individual has as a result of an injury or illness or that a physician places on a person to prevent aggravating an injury or illness.
In the first case, the limits are a semi-measurable quantity that can be verified through a test called a functional-capacity evaluation (FCE). The second instance concerns more-subjective limitations that are established by a physician to protect a patient’s well-being.
An example of a physical restriction or limitation would be:
In an 8-hour workday, how often could the patient lift 0-5 pounds: frequently, occasionally or never.
During an 8-hour workday, on a regular and continuing basis, how long can the beneficiary stand or walk without taking a rest: 1 hour, 2 hours, 3 hours, etc.
Insurance companies and plan administrators rely upon restrictions and limitations to determine if a beneficiary can perform their job’s physical functions. These functions are determined by the individual job description and the Department of Labor classification of what duty level the job is (heavy duty, medium duty, light duty or sedentary).
Denial of Long- or Short-Term Disability Benefits: Evidence
Without medical evidence specific to the beneficiary’s restrictions or limitations (or sufficient medical evidence supporting the restrictions and limitations), it is common for an insurer or plan administrator to determine that “there is no evidence that the beneficiary is disabled from the material job functions” and therefore the individual is not disabled under the plan. This denial comes despite objective medical evidence that the individual is severely injured or suffering from a debilitating illness.
Obtaining the right evidence during the appeal is crucial to proving your right to long- and short-term disability insurance benefits. That evidence changes depending on what your specific disabling injury or illness is. The right evidence can be an FCE that outlines the objective findings of what your physical limitations are. It also could be medical evidence that proves doing more of certain activities will worsen the symptoms.
The ERISA and disability lawyers at Gallagher Davis have years of experience in analyzing claim files and specific conditions to determine what evidence is best, whether that is a written statement from a treating physician, an FCE or an independent medical examination to corroborate treating physicians’ opinions.
Because claims for long- and short-term disability insurance benefits are often covered by ERISA law, failing to submit the proper evidence as part of the appeal will affect the ability to pursue the claim in federal court. The federal court is generally limited to reviewing the claim to determine if the insurance company or plan administrator was reasonable in the decision it reached. This standard prevents the presentation of new evidence during the court’s review. In short, if the evidence is not produced as part of the internal review, it will not be considered if presented during litigation.
ERISA and Disability Lawyers: Contact Us Today
The seasoned ERISA and disability lawyers at Gallagher Davis, LLP support company employees in the review, filing and appeal of long- and short-term disability insurance benefits claims.
With experience in all state and federal trial and appellate courts in the St. Louis metropolitan area, as well as throughout Missouri and the Midwest, our lawyers for disability provide you with vigorous advocacy and representation in justly receiving available benefits for which you are qualified as you recover. To discuss your case, contact us today at (314) 725-1780. We offer free consultations.