ERISA Disability Claims

ERISA disability claims look like insurance disputes from the outside. They are not. They are federal administrative proceedings governed by a body of law that favors the carrier in ways most claimants do not realize until the denial letter arrives.

What ERISA Disability Cases Involve

Most employer-provided long-term disability policies are governed by the Employee Retirement Income Security Act of 1974. ERISA preempts state insurance law and imposes a specific procedural framework on how claims are filed, how denials are reviewed, and what evidence a court can consider in litigation. Claimants who treat an LTD claim like an ordinary insurance matter routinely lose, often before they realize anything has gone wrong.

The Administrative Appeal Is Critical

After a denial, the claimant typically has 180 days to file an administrative appeal with the insurance carrier. This is the last meaningful opportunity to put evidence in the record. If the case ends up in federal court, the judge is usually limited to the administrative record that existed when the carrier made its final decision. New medical records, new physician opinions, new vocational evidence, none of it can be added later. The administrative appeal is where the case is built or lost.

The firm prepares ERISA appeals with the same attention given to a federal complaint, including:

• Comprehensive medical record review and supplementation
• Treating physician statements addressing the specific definition of disability in the policy
• Vocational expert reports when the carrier disputes occupational requirements
• Functional capacity evaluations where appropriate
• Responses to peer review reports the carrier obtained from its own consultants
• Detailed legal arguments addressing the specific reasons for denial

Federal Court Litigation

If the administrative appeal is denied, the next step is federal court. ERISA actions are filed in district court without a jury. The standard of review depends on the policy language. If the plan grants the administrator discretion, the court reviews under the deferential arbitrary and capricious standard. If not, the court applies de novo review, which gives the claimant a much better chance.

Common Issues in Denied Claims

Insurers deny LTD claims for predictable reasons. The most common include disputes about whether the claimant is unable to perform the duties of his or her "own occupation" or "any occupation," reliance on surveillance footage or social media activity, peer reviews from physicians who never examined the claimant, alleged failure to follow recommended treatment, and policy limitations on mental health and self-reported symptom conditions. Each of these has a legal response, and each requires a different evidentiary build-out in the administrative record.

Remedies

A successful ERISA case typically results in reinstatement of benefits, payment of back benefits, prejudgment interest, and attorney fees. The firm pursues all available remedies. The goal is not just to win the lawsuit but to put the client back where the policy promised.

If your long-term disability claim has been denied or terminated, the firm welcomes a conversation about the policy, the denial letter, and the next steps.