How Does ERISA Affect My Long-Term Disability Claim in Pennsylvania?

If you have a long-term disability insurance policy through your employer in Pennsylvania, it will be held to the standards set by the Employee Retirement Income Security Act (ERISA).

When employers provide benefit packages to employees, they must do so according to ERISA, which imposes a fiduciary duty on employers and insurers when handling employee claims and assets. Depending on your policy, the definition of disabled might differ. Furthermore, your coverage may not be portable if you change companies in Pennsylvania, which is might require you to supplement your income using other means, such as disability benefits from the Social Security Administration (SSA). If you were denied long-term disability benefits after submitting your claim, our lawyers can help you navigate the appeals process so that you can get the payout you deserve.

Call the Pennsylvania disability lawyers of Young, Marr, Mallis & Associates at (215) 515-2954 to get a free assessment of your case today.

How Does ERISA Affect Long-Term Disability Policies and Claims in Pennsylvania?

The Employee Retirement Income Security Act sets standards for how employers must provide retirement, health, disability, and other insurance and benefits plans to employees. Because of ERISA, you might have an easier time getting benefits through your employer-backed long-term disability insurance policy.

The Employee Retirement Income Security Act does not require employers to provide benefit plans to employees. But, if employers do choose to provide these voluntary policies, ERISA governs the standards of such plans. The goal of ERISA is to reduce instances of employees being denied previously promised benefits, such as long-term disability insurance benefits.

Among other things, ERISA sets standards regarding the fiduciary duty of employers and benefit providers to treat employee benefits as they would their own assets. This is so that employers do not misuse employee assets, leaving them without the benefits they were guaranteed.

The Employee Retirement Income Security Act also requires employers with benefit plans to disclose certain information regarding such plans to employees and dictates that employers must provide employees with the information necessary to submit a claim under a benefit policy. Furthermore, ERISA gives participants of employer-backed retirement or long-term disability plans the right to sue their employers for the misuse of assets or another breach of their fiduciary duty. While ERISA largely focuses on retirement benefits, it sets standards for other plans, like employer-backed disability insurance policies. All of that is to say, ERISA should positively affect your long-term disability claim, as it requires insurers to give a full and fair review of all claims.

What Qualifies as Disabled Under Long-Term Disability Policies in Pennsylvania?

Under ERISA policies, long-term disability benefits may be paid out to an injured claimant if they are unable to perform their previous workplace duties or any workplace duties at all. Which disability standard applies to your claim will depend on your policy.

The two terms to familiarize yourself with when it comes to determining disability under your employer-backed policy are “own occupation” and “any occupation.” Usually, own occupation would be defined as the job the person was performing at the time they were disabled. Under such a definition, a disability would exist when, due to illness, accident or injury, the person is unable to perform the material and substantial duties of their regular occupation. Therefore, you are disabled under this definition if you are unable to carry out the duties of your specific job.

Some policies are own occupation throughout while others have a defined period in which own occupation applies, such as one year or two years. Unlike under own occupation policies, the standard of disability under an any occupation policy is more difficult to meet. This is because you must demonstrate that you are unable to perform any job for which you are reasonably qualified based on your education, training or experience. This will require our lawyers to present your medical records as evidence of the extent of your disability in Pennsylvania.

Are ERISA Long-Term Disability Benefits Portable if You Leave Your Company in Pennsylvania?

While working at a company in Pennsylvania, you might purchase long-term disability insurance through your employer in case you are injured and can no longer work. If you change companies, will your plan be portable?

If you purchased your disability through your employer, it is important to know whether you can maintain that policy upon leaving the company. Obviously, this is not an issue if it is a privately purchased policy. Because the majority of ERISA-based policies are not portable, it is something you should be aware of. If your plan is not portable, it is that much more of a reason to consider purchasing an additional policy outside of employment.

Suppose you recently become disabled and can no longer work, only to learn that your long-term disability insurance policy was not portable when you moved companies. In that case, you might be eligible for other benefits. For example, those who can no longer work because of illness, injury, or disability can often get Social Security Disability Insurance (SSDI) benefits through the Social Security Administration. Our Pennsylvania disability lawyers can examine your work history and medical records to see if you meet the Social Security Administration’s definition of disabled. We can also estimate your monthly benefit amount so that you can organize your finances accordingly.

Does ERISA Impact Long-Term Disability Policy Exclusions in Pennsylvania?

In addition to the definition of disability, many employer-backed long-term disability insurance policies cite certain conditions that are excluded either because of pre-existing conditions or because they are simply not covered. For example, mental health conditions often are either not covered or only covered for a limited period of time. It is important that you be aware of these exclusionary provisions when making a claim in Pennsylvania.

Regarding pre-existing conditions, insurance companies might evaluate them within two specific time periods. For example, the insurance company might want to look back at your medical records over the past several months or years to determine if you showed signs of a specific condition, illness, or injury prior to submitting your claim.

Then, there is a waiting period, which is the amount of time you must wait after getting a long-term disability insurance policy through your employer before a pre-existing condition can be covered. This might be anywhere between one to two years, depending on your specific policy in Pennsylvania.

Other common policy exclusions that lead to a reduction in long-term disability benefits include alcohol or substance abuse and intentionally causing one’s disability to receive benefits. Our Pennsylvania disability lawyers can provide the insurance company with all necessary information regarding any pre-existing conditions you might have and provide context to your medical records so that you can get the greatest benefits available to you according to your policy.

Long-Term Disability Insurance Policy Coverage and Maximum Benefit Periods in Pennsylvania

Each long-term disability insurance policy is unique, whether it is governed by ERISA or privately purchased. Our lawyers can examine your plain to determine its coverage limits and maximum benefit period.

For example, some long-term disability insurance policies will have a cap as to payment amounts, while others will pay a percentage of your pre-disability gross income. It is our experience that it is rare for a policy to pay higher than 70% of pre-disability earnings as they wish to incentivize your return to employment. It is important to know this dollar amount as you may need to supplement an employer-based policy with a private policy to cover basic living expenses.

Every policy comes with a maximum benefit period, usually until age 65 or 67. This is the maximum amount of time benefits can be paid under a policy. Furthermore, all policies have an elimination period before beginning paying benefits. While each policy is different, in general, you will usually see employer-based policies with a minimum elimination periods of 90 days. It is also important to know that whether your long-term disability benefits are taxable or not will depend on whether they were paid with before or after-tax dollars. If your employer paid premiums with before-tax dollars, your benefits will be taxed. Comparatively, if it is a private policy or paid for with after-tax dollars, the benefits will be paid tax free.

What Should I Do If I Was Denied ERISA Long-Term Disability Benefits in Pennsylvania?

If you were denied long term disability benefits, it is important to contact qualified counsel to examine both your policy as well as the internal rules concerning the appeal process. You must exhaust your insurance internal appeals process before you can proceed to federal court.

Under ERISA policy, court judges are limited to reviewing the record that was presented to the insurer to determine whether their decision was “arbitrary and capricious”. Therefore, it is critical that you supplement the administrative record with as much prohibitive evidence as possible prior to it being closed. While some companies will allow a second appeal, others only have one appeal and failure to provide these records can be hugely detrimental.

What if Your Pennsylvania Employer Does Not Offer a Long-Term Disability ERISA Policy?

If your employer does not offer long-term disability insurance policies and is not governed by ERISA, that does not mean you are without hope if you can no longer work because of a disability. There might be government-backed disability programs you are eligible for.

Remember, ERISA does not require employers to offer workers benefits. Instead, it simply governs how employers must offer such benefits if they choose to do so. This might mean that your employer does not provide an option for you to purchase long-term disability insurance through them. In that case, you can purchase a private plan. Or, if you were hurt and can no longer work, our lawyers can help you file a claim for Social Security Disability Insurance benefits.

Such benefits are only available to those who have worked a considerable amount of time and have paid into the system. This is done when your employer removes Social Security taxes from your paycheck. The sum of monthly SSDI benefits varies from recipient to recipient. We can help you apply for SSDI benefits through the Social Security Administration. This process might be similar to getting benefits through an employer-backed long-term disability insurance policy in that you will have to provide the SSA with information regarding your medical condition and history.

Call Our Disability Lawyers in Pennsylvania Today

Call Young, Marr, Mallis & Associates at (215) 515-2954 to have our Pennsylvania disability lawyers review your case for free.