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HomeDisability InsuranceIs Your Long-Term Disability Claim Governed by ERISA?

Is Your Long-Term Disability Claim Governed by ERISA?


When dealing with a long-term disability denial, understanding if your claim falls under the Employee Retirement Income Security Act (ERISA) can significantly impact the process and outcome of your claim.

ERISA, a federal law that sets standards for most employer-sponsored retirement and health plans, also governs certain long-term disability insurance policies. If your disability claim is subject to ERISA regulations, it can affect your rights and legal options in case of a dispute.

When evaluating whether your long-term disability claim falls under ERISA regulations, several factors come into play. Understanding the key indicators can help you determine if ERISA governs your claim.

Does ERISA Law Apply to My Claim?

Reviewing plan documents can help determine whether your long-term disability claim falls under ERISA guidelines. These documents outline the terms of your disability benefits, including eligibility criteria, coverage details, and claims procedures.

Several other key indicators can also provide valuable insights into whether ERISA governs your long-term disability claim. Understanding these indicators can help you navigate the complexities of ERISA coverage more effectively.

Employer-Sponsored Plans

One key indicator that ERISA may govern your long-term disability claim is if the insurance coverage is provided through your employer rather than being individually purchased. Employers establish these plans for their employees and provide benefits such as long-term disability coverage. If your disability benefits are tied to your employment and your employer is involved in the management or funding of the plan, it’s likely subject to ERISA.

As further explained in the next section, ERISA applies to most group plans with employers that are in the private sector. Government employees who are employed by city/municipal, state, or federal employers may be exempt from ERISA.

Government Employees and Church Plans

Certain exceptions exist for government employees and church plans regarding ERISA coverage. Government employees, including those working for federal, state, or local agencies, may have disability benefits governed by separate regulations outside of ERISA. Similarly, church plans maintained by religious organizations for their employees may not always fall under ERISA requirements.

Self-Funded vs. Insurance Company Plans

When determining ERISA applicability, distinguishing between self-funded plans and insurance company policies is crucial.

Self-funded plans are funded by the employer and managed internally, while insurance company plans involve purchasing coverage from an insurance provider.

Self-funded plans are more likely to be subject to ERISA regulations due to the direct involvement of the employer in administering the benefits, whereas traditional insurance policies may have different regulatory frameworks.

Understanding the nuances of employer-sponsored plans, exceptions for specific groups, and the differences between self-funded and insurance company plans is essential to determine whether ERISA regulations govern your long-term disability claim.

An ERISA Attorney at Ortiz Law Firm Can Help with your Long-Term Disability Claim

Working with an attorney specializing in ERISA cases can significantly affect the outcome of your long-term disability claim. These legal professionals have the expertise and experience to guide you through the intricate legal processes involved in ERISA claims. They can help you understand your rights, evaluate your claim’s strength, and advocate on your behalf with insurance companies.

Appealing Denied Claims

If your long-term disability claim under ERISA has been denied, appealing the decision is a critical next step. An attorney can assist you in navigating the often complicated appeals process. They can help gather relevant evidence, prepare a persuasive appeal, and represent you during any necessary court proceedings or negotiations with the insurance company. With their support, you can increase your chances of a successful appeal and securing the disability benefits you deserve.

Filing a Lawsuit

Under ERISA regulations, claimants must exhaust all administrative remedies before pursuing legal action in federal court. If your long-term disability appeal gets denied, an ERISA attorney can help you file a lawsuit against the insurance company. Consulting with legal experts and being well-informed about the legal procedures can help you make informed decisions regarding the course of action for your disability claim and give you the best chance of winning your case in court.

Call Us Today for a Free Case Review

ERISA attorney Nick Ortiz is the founder of the Ortiz Law Firm. Since 2005, he has dedicated his practice to helping individuals who have been denied the disability benefits they deserve. He offers a free case review for claimants facing a long-term disability claim denial and a zero-fee guarantee to each client. You only pay a fee if there is a recovery. Call (888) 321-8131 to schedule your case review today.