Understanding How ERISA Applies To Long-Term Disability Claims In Florida

If your employer provides long-term disability coverage, you may think that a disabling condition is all it takes to start receiving benefits. Unfortunately, the reality is far more complicated. Insurers frequently denied claims, and the Employee Retirement Income Security Act (ERISA) governs the appeals process.

Understanding how ERISA applies to disability claims is important for protecting yourself and your benefits. Our experienced Jacksonville long-term disability lawyer explains common tactics insurers use to deny claims and your rights under ERISA.

Common Tactics Used to Deny Florida ERISA Disability Claims

Employer-provided disability insurance can provide a lifeline if a chronic health condition or serious injuries leave you unable to work. However, keep in mind that insurers are for-profit businesses. To protect their bottom line, they use a variety of tactics to deny and dispute long-term disability claims. These include:

• Claiming insufficient medical evidence, even when you have detailed records from treating physicians.
• Ordering independent medical examinations by physicians who review files without ever meeting you.
• Using surveillance or social media activity to argue that daily activities contradict claimed limitations.
• Shifting the policy definition of disability from “own occupation” to “any occupation” after 24 months, then terminating benefits if you can perform some other type of work.
• Applying pre-existing condition exclusions broadly, sometimes covering conditions that worsened or changed significantly after the policy began.

Under ERISA, you have the right to file an administrative appeal if denied long-term disability benefits in Florida. Unfortunately, while originally designed to protect workers, it can actually benefit insurers more.

How ERISA Creates a Playing Field That Favors Insurers

ERISA helps protect employees by setting minimum standards for employer benefit plans. However, its rules give insurance companies enormous advantages when evaluating and denying disability claims.

Unlike disputes over individual insurance policies, governed by Florida state law, ERISA cases are heard exclusively in federal court by a single judge. Disadvantages Florida claimants face under ERISA include:

• The insurer reviews its own denial on appeal, rather than an independent party.
• Courts typically defer to the insurer’s decision unless the claimant can prove it was “arbitrary and capricious,” one of the highest legal standards in civil law.
• No jury trial is available: a single federal judge decides the case based solely on the existing administrative record.
• Punitive damages, bad-faith claims, and compensation for emotional distress are unavailable, meaning insurers face little financial consequences for wrongful denials.

Because of that last point, insurers know the worst outcome is typically an order to pay the benefits they already owed. In this way, ERISA actually encourages denials.

Contact Our Experienced Jacksonville Long-Term Disability Lawyer

If you were denied long-term disability benefits in Florida, ERISA typically provides 180 days to file an appeal. To build a strong case, contact Farrell Disability Law right away.

Our experienced Florida long-term disability lawyer can review your denial, your policy, and your claims file to help you build the strongest possible appeal. To get the benefits you deserve, request a consultation today at our Orlando or Jacksonville office.

Sources:

dol.gov/general/topic/retirement/erisa

dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/publications/filing-a-claim-for-your-disability-benefits.pdf https://www.federalregister.gov/documents/2016/12/19/2016-30070/claims-procedure-for-plans-providing-disability-benefits