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Avoid a Claim Killer – Retain An ERISA Disability Attorney Before You Appeal a Claim Denial

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The most common and fatal mistake people make in their ERISA disability claim is not consulting with and retaining, an experienced ERISA attorney soon after their claim is denied.  People make this mistake for various reasons including the insurance company not informing you to retain an attorney and your not knowing you can and should retain an attorney at that time.  Others may believe their insurance company made a mistake which can be easily fixed with their only appeal.  Finally, some people believe they are “saving money” by not retaining a lawyer.

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Statute of Limitations – A Case Study

Mirza v. Ins. Admin. Of America, Inc., 800 F.3rd 129 (3d Cir. 2015)

 

The legal issue in Mirza involved whether insurance companies and plan administrators must inform claimants of plan or policy imposed deadlines for judicial review (i.e. filing a lawsuit) and the court held that they must pursuant to ERISA, 29 C.F.R §2560.503-1(g)(I)(iv).

The court quoted 29 C.F.R. § 2560.503-1(g)(1)(iv), which requires plan administrators to set forth a “description of the plan’s review procedures and the time limits applicable to such procedures, including a statement of the claimant’s right to bring a civil action under section 502(a) of the Act following an adverse benefit determination.

The court found in Dr. Mirza’s favor based on a review of ERISA’s regulations which requires “a notification of the timeframes involved for enforcing one’s rights and practical considerations given that the plan at issue was 91 pages long and its statute of limitation provision was buried on page 73.

 
When the insurance company denied Dr. Mirza’s claim for reimbursement for performing a surgery it advised him of the right to bring a lawsuit to challenge the denial but did not inform him that the lawsuit had to be brought within one year of the denial in order to be timely.  Although Dr. Mirza filed the lawsuit within the six year statute of limitations provided for by New Jersey law he did not file it within one year of the denial.  The court found in Dr. Mirza’s favor based on a review of ERISA’s regulations which requires “a notification of the timeframes involved for enforcing one’s rights and practical considerations given that the plan at issue was 91 pages long and its statute of limitation provision was buried on page 73.

The court found the appropriate remedy in Dr. Mirza’s case was to set aside the plans one year time limit and instead it applied the limitations period from the most analogous state law cause of action which was New Jersey’s six year deadline to enforce a breach of contract claim.

The court’s decision in the Mirza case will undoubtedly assist insured’s and plan beneficiaries by providing clarity and certainty that 1. they have a legal remedy to pursue judicial review, the decision of which is very often a financially conflicted insurance company and 2. The important timeframes which need to be adhered to in order to pursue those claims.

The issue of whether an insurance company and ERISA plan administrator needs to advise an insured or beneficiary of the timeframes involved to pursue their legal remedies in Federal Court has seen considerable litigation over the years.  The court’s decision in the Mirza case will undoubtedly assist insured’s and plan beneficiaries by providing clarity and certainty that 1. they have a legal remedy to pursue judicial review, the decision of which is very often a financially conflicted insurance company and 2. The important timeframes which need to be adhered to in order to pursue those claims.

 

Beware of Working Part Time In The Months Before Filing a Disability Claim

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By Scott E. Davis, Disability Attorney

For many people who are struggling to work due to an acute unexpected medical condition, they do not have the opportunity to prepare or plan for filing a short and or long term disability claim.  My experience is that most people who eventually file disability claims, have chronic medical conditions which have been ongoing for months and even years. Continue reading

Beware Of And Avoid This Disability Policy Trap!

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By Scott E. Davis, Disability Attorney

The title of this article could also be named, “how to avoid the psychological benefit limitation” that is likely lurking in your company’s disability policy.

When people are unable to work and their short and/or long term disability claim is approved, whenever it can, the disability insurance company often uses a psychological diagnosis as the basis for paying the claim regardless of any physical diagnoses which you may believe are disabling.  Indeed, even if you filed your disability claim based on a physical diagnosis, if you also have much smaller psychological issues such as depression or anxiety as a result of your inability to work, the insurance company can say that it is approving your claim based on the psychological diagnosis. Continue reading

What Is ERISA? Why Is It So Bad?

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By Scott E. Davis, Disability Attorney

ERISA is the acronym for the Employee Retirement Income Security Act of 1974.  ERISA is a very broad, far reaching and complex federal law that governs every American employee’s benefits at their workplace.

Since it is federal law, ERISA supersedes and replaces state law, even though your state law may provide you with more consumer protections than ERISA does.  Over the course of the last four decades, a law that was initially meant to provide protections to American workers has become employer and insurance company friendly while providing few obvious protections for American workers.  While ERISA does charge your insurance company or employer with a fiduciary duty to administer your employee benefits in a full and fair manner, the reality is, this does not occur. Continue reading

Is Your Insurance Company Allowed to Disregard Your Doctor’s Statement That You Are Disabled?

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By Scott E. Davis, Disability Attorney

Many people, as well as their medical professionals, mistakenly believe that when they file a claim for short and/or long-term disability benefits, their disability insurance company has to accept their medical professional’s (doctor’s) statement that they are disabled.  Common sense suggests this is a reasonable assumption – but it couldn’t be further from the truth.  Why? Because so many insurance companies simply do not want to pay people’s disability claims and when armed with discretionary language in the policy as they frequently are – the insurance company has the final and only say on whether you are disabled, not your doctor.

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Why Do Insurance Companies Say You Are Disabled Due to a Psychological Disorder?

 

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By Scott E. Davis, Disability Attorney

When people are unable to work and their short and/or long term disability claim is approved, the disability insurance company often uses a psychological diagnosis regardless of a physical diagnosis. This if often true even though you may have primarily physical diagnoses and have filed your claim on that basis. So, why would an insurance company do this? Continue reading