Typically a group policy provided to you by your employer is governed by The Employee Retirement Income Security Act of 1974 (“ERISA”), a federal law that provides standards for how a claim is administered, including deadlines imposed on employees and insurance carriers for the filing, responding and appealing of a claim for benefits. While ERISA was enacted to protect workers, in practice it favors employers and carriers who know how to manipulate the facts, the claims process and the laws.
Carriers dedicate an enormous amount of time and resources to build a case for their denial of your claim for benefits which includes conducting surveillance and demand an independent medical evaluation (IME) or functional capacity evaluation (FCE),which they either may not have a right to conduct or if they do, they are may be conducting it in an manner inconsistent with their rights under the terms of the policy. For example, the carrier may schedule the evaluation to be conducted in another state or city, by someone other than a medical doctor or even an uninsured provider.
The filing of an insurance claim may appear to be an easy task; however, the insurance carriers’ forms are designed to ask general and vague questions which then allow the carrier to unduly delay your claim under the disguise that they need additional information and documentation.
You should know that most disability income insurance claims are denied. Under ERISA you have 180 days to appeal a denial of benefits which begins to run as of the date you receive the denial letter. It is extremely important that you know your responsibilities as well as the carriers obligations and timely act through the claims process in order to protect your rights. You have an obligation to appeal the carrier’s denial of your claim in a timely manner.
Unfortunately it is not an even playing field; the law favors the employer and carrier and as such, you must be aware of your rights and responsibilities under ERISA and under the terms of your disability income insurance policy. Know and defend your rights by seeking a lawyer with experience in dealing with ERISA and the insurance carriers.