If you receive disability insurance through your employer, you might assume that filing a claim will be straightforward. After all, you’ve paid for coverage—either directly or through your employee benefits package—and you need those benefits because a medical condition is preventing you from working.
Unfortunately, many employees discover that obtaining disability benefits through an employer-sponsored plan is far more complicated than expected. They may even find their ERISA disability claim denied.
Most employer-sponsored disability plans are governed by the Employee Retirement Income Security Act of 1974 (ERISA), a federal law that establishes rules for employee benefit plans. While ERISA was intended to protect workers, it also creates unique procedural hurdles that can make disability claims and appeals challenging.
At Bryant Legal Group, our Chicago disability attorneys regularly help professionals, executives, physicians, and other employees navigate ERISA disability claims. We’ll explain how this type of insurance works, why so many claims are denied, what employers and insurance companies don’t always tell you, and how an experienced disability attorney can help protect your rights if your ERISA disability claim is denied.
What Is an ERISA Disability Claim?
ERISA is a federal law that governs most employer-sponsored benefit plans, including:
- Retirement plans and pensions
When you file a disability claim through your employer-sponsored disability plan, you are often subject to ERISA’s rules and procedures.
Unlike an individual disability insurance policy that you purchase directly from an insurance company, an ERISA disability claim is governed primarily by federal law rather than state law.
This distinction matters because ERISA significantly affects how claims are reviewed, the types of evidence you can submit, and the options you have if your ERISA disability claim is denied.
However, many employees don’t realize they are dealing with an ERISA claim until after they’ve received a denial letter.
How Does Employer-Sponsored Disability Insurance Work?
Most employer-sponsored disability plans provide income replacement if a medical condition prevents you from working. Generally, the process looks like this:
Step 1: You Submit a Claim
You complete claim forms and provide medical evidence supporting your disability. This often includes:
Step 2: The Insurance Company Reviews Your Claim
Although the policy is provided through your employer, the claim is usually administered by a private insurance company such as Unum, Hartford, Lincoln Financial, MetLife, or Prudential.
The company will review the claim and determine whether benefits will be approved.
RELATED: Long-term Disability Denial Hub
Step 3: Ongoing Monitoring
If your claim is approved, the insurer will continue reviewing your case. You may be asked to provide:
- Updated medical records
- Attending physician statements
- Functional capacity evaluations
Many claimants are surprised to learn that approval is not permanent. Insurance companies frequently re-evaluate claims and may terminate benefits later.
Why Are ERISA Disability Claims Denied?
Insurance companies deny ERISA disability claims for many reasons. Some denials are legitimate. Others are based on incomplete information, flawed reviews, or aggressive claim management practices.
1. Insufficient Medical Evidence
This is perhaps the most common reason for denial. An insurer may argue that:
- Your records don’t support your limitations
- Your symptoms are subjective
- There isn’t enough objective evidence
This often affects claimants suffering from conditions such as fibromyalgia, chronic fatigue syndrome, migraines, long COVID, chronic pain, and mental health conditions.
2. Failure to Meet the Policy’s Definition of Disability
Every disability policy defines “disability” differently. Some policies use an “own occupation” standard while others use an “any occupation” standard.
Insurance companies frequently argue that although you can’t perform your previous job, you can perform another occupation.
RELATED: What Do Own Occupation and Any Occupation Mean in Disability Claims?
3. Surveillance and Social Media Reviews
Many insurers conduct surveillance across multiple channels. They may:
- Review social media accounts
- Monitor public activities
Even a short video clip or photograph taken out of context can be used to challenge your claim.
4. Reliance on Insurance-Hired Doctors
Insurance companies often hire physicians to review records or conduct examinations. These doctors may never treat you and may spend very little time evaluating your condition, yet their opinions are frequently used to justify denials.
5. Missed Deadlines or Paperwork Issues
ERISA claims involve strict procedural requirements.
Missing a deadline or failing to submit requested information can result in a denial, even if your disability is legitimate.
RELATED: Do You Know the Deadline for Filing Your ERISA Claim?
What Employers and Insurance Companies Don’t Tell You
Many claimants unexpectedly enter the ERISA appeal process without much time for review or preparation. They might not be aware of several critical realities that can help them.
RELATED: Denied ERISA Short-Term Disability Benefits? Follow This Appeal Checklist
Your Appeal Is Often Your Most Important Opportunity
Many people assume they can submit additional evidence later if necessary. But under ERISA, that often isn’t true.
In many cases, the administrative appeal is the only opportunity to add evidence to the insurance company’s claim file, which often becomes the record that the court will review. If critical evidence isn’t submitted during the appeal process, you may lose the opportunity to introduce it later.
The Insurance Company Is Building a Case Against Your Claim
Insurance companies don’t simply evaluate evidence. They actively look for reasons to deny claims. Adjusters may search for:
- Activities that appear inconsistent with disability
- Statements from doctors that can be interpreted against you
You May Have Limited Remedies
Under many ERISA plans, you cannot recover certain damages that might otherwise be available under state law. This can significantly affect your legal options.
Your Employer Is Not Your Advocate
Many employees assume their employer or human resources department will help protect their interests if problems arise with a disability claim. While HR personnel are often well-intentioned and may try to assist, it is important to understand that neither your employer nor HR serves as your personal advocate in the claims process.
In most cases, your employer does not control claim decisions. Once a claim is submitted, the insurance company typically assumes responsibility for evaluating eligibility, requesting information, and determining whether benefits will be approved, continued, or terminated.
Employees should also exercise caution when relying on advice from an employer or HR representative regarding disability benefits. Human resources professionals generally are not disability insurance specialists, attorneys, or claims professionals, and they may not fully understand the policy terms, applicable legal requirements, or the potential consequences of a particular course of action. Even well-intentioned guidance may be incomplete or incorrect.
For that reason, claimants should independently review their policy documents, carefully evaluate communications from the insurer, and seek qualified advice when significant benefits are at stake.
How a Chicago Disability Attorney Can Help
Because ERISA disability claims involve strict rules and deadlines, legal guidance can be invaluable. At Bryant Legal Group, we assist clients at every stage of the process.
Before Filing
We help clients:
- Understand disability definitions and policy exclusions
- Identify potential claim weaknesses
- Gather strong supporting evidence
During the Claim
We work with treating physicians, vocational experts, and medical specialists to develop evidence that clearly explains why our clients cannot work.
During the Appeal
Appeals are often the most important stage of an ERISA claim. We help clients:
- Address insurer arguments
- Obtain additional evidence
- Build a comprehensive administrative record
Litigation
If the insurance company continues to deny benefits, our attorneys can pursue legal action under ERISA and advocate aggressively for our clients.
Frequently Asked Questions About ERISA Claims and Denials
How long do I have to appeal an ERISA disability denial?
Most ERISA plans provide 180 days to file an appeal, but deadlines vary. Missing an appeal deadline can permanently harm your claim.
Do I need a disability attorney before filing a disability claim?
Not always, but many claimants benefit from legal guidance before submitting their application. Early preparation can help avoid mistakes that later lead to denials.
What is the difference between an ERISA claim and an individual disability policy?
ERISA claims involve employer-sponsored plans and are governed by federal law. Individual disability policies are typically governed by state law and may provide additional legal remedies.
Can I work while receiving disability benefits?
Possibly. Some policies allow partial or residual disability benefits. However, returning to work without understanding your policy’s rules can jeopardize your claim.
What if my disability is based on pain, fatigue, or mental health symptoms?
These claims can be more challenging but are often valid. Strong medical documentation and a clear explanation of your functional limitations are critical.
What should I do if my benefits are terminated?
Contact a disability attorney immediately. Termination letters typically trigger important appeal deadlines, and delaying action can make it more difficult to protect your rights.
Bryant Legal Group Helps Employees Fight Back Against Wrongful ERISA Denials
When an illness or injury prevents you from working, disability benefits may be your primary source of financial security. Unfortunately, many employees discover that obtaining those benefits is far more difficult than they expected.
At Bryant Legal Group, we understand the challenges of ERISA disability claims. Our attorneys have extensive experience helping professionals and workers navigate complicated disability insurance disputes, appeal denials, and pursue the benefits they deserve.
If you’re considering filing an ERISA disability claim or have received a denial letter, contact Bryant Legal Group today for a confidential consultation. We’ll help you understand your options, protect your rights, and develop a strategy tailored to your unique situation.
The content provided here is for informational purposes only and should not be construed as legal advice on any subject.