Frequently Asked Questions

Yes. Just because you were paid does not mean the insurer acted in good faith. Any delays or misconduct that causes you to wait for payments or experience a financial loss are grounds for a bad faith claim. In fact, the insurance company may have been lowballed you with their initial offer, and that can also be grounds for a bad faith claim.

Not necessarily. Many insurance bad faith claims settle outside of court rather than going all the way to a jury trial. As we work on your case, we’ll keep you updated about settlement negotiations and whether it’s worth going to court to maximize compensation. If we do go to trial, we’ll be a fierce advocate for you every step of the way.

The following employee plans are not subject to ERISA regulations:

• Workers’ Compensation Benefits
• Unemployment
• Social Security Disability Benefits
• Government Employee Plans
• Church/Religious Employee Plans
• Small Insurance Plans
• Plans of Indian Tribal Governments
• Insurance Plans Outside of the U.S.
• Unfunded Excess Benefit Plans

As a general rule, ERISA does apply to exempt employers and exempt plans.

• Exempt employers include government employers and religious employers. For government employers, their plans tend to be subject to other federal laws or state laws. For religious employers, federal ERISA laws do not apply, which is one way that the church and state are kept separate.
• Exempt plans include any plans that you do not have through your employer. This applies to any insurance you paid for yourself out of your own pocket (i.e., not through payroll deductions) as well as plans subject to other laws, such as workers’ comp and certain kinds of disability coverage.

Learn more about plans that are not subject to ERISA regulations.

“LWOP” stands for Life Waiver of Premium. This is a provision that may be included in a life insurance policy that allows the beneficiary to stop paying premiums but continue receiving benefits if they become disabled. We can determine if this applies to your situation and help you understand this separate claims process.

For employer-provided disability coverage, your policy ends when your employment ends. In some cases, you may be given the option to convert your group policy to an individual policy, though this must be done within a specified timeframe after you’ve left your job. The terms of this individual policy may not be the same as your group policy with your former employer.

Yes. This is also known as an elimination period. You must be continuously disabled and unable to work for a certain amount of time before you can receive long-term disability payments from the insurer. This elimination period can be as short as 30 days from the date of diagnosis or as long as a year. Be sure to check your policy for details on your elimination period.

Potentially, yes, but it must be in a limited capacity, meaning only part-time and in a less-demanding field. Keep in mind that your insurer will offset your long-term disability benefits based on earnings from your other line of work.

Before filing a lawsuit, a claimant must exhaust the available remedies under the plan, so long as the plan’s procedures are reasonable. This typically means a claimant must apply for benefits in accordance with the plan’s application procedures. If the claim is denied, the claimant must appeal under the plan’s appeal procedures. A claimant is required to “exhaust” his or her administrative remedies before filing an action in court.

It is crucial to understand that the record closes when the insurance company or ERISA administrator issues its final decision.  Claimants must submit all the evidence they want to be considered during the administrative appeal process, and may not submit new evidence regarding the merits of their claim once the case is in court.

In other words, the basic rule is that the record closes when the administrator or insurance company makes its final denial, and it is often impossible to submit new evidence in litigation that was not sent to the insurance company before it denied the claim. This typically leads to extremely curtailed records requests and reviews by insurers. Willful blindness helps them later on in court.

From December 1, 2012, to December 8, 2017, there were 380 cases coded in Pacer as 791 (ERISA) in Alabama’s three federal districts. Excluding government actions, actions brought by the insurer, and class action cases which were not individual ERISA benefits cases, only 20 cases (5.26%) out of 380 cases coded as 791 (ERISA) in CM/ECF went the distance to a final decision in all three of Alabama’s districts. Remember, there are no jury trials under ERISA, so this typically meant it was decided via dispositive briefing.

Of the 20 cases that went to a final decision, only four resulted favorably for the plaintiff. Out of 380 ERISA cases, the individual won 4 times.  Improving your client’s odds of winning requires an understanding of the importance of ERISA’s administrative remedies.

ERISA divides employee benefits into two broad categories: pension benefits and welfare benefits. Long-term disability benefits, health insurance, life insurance, dental insurance, and similar benefits fall under “ERISA welfare benefits.” If an ERISA plan participant or beneficiary is denied those benefits, the person must go through the ERISA plan’s required appeal procedures. If the claim is still denied, the person can then bring an action under ERISA § 502(a)(1)(B) (29 U.S.C. § 1132(a)(1)(B)).

Because ERISA preempts any state law remedies, a plaintiff may only obtain those remedies available under the ERISA statute and case law. Usually, this is a remedy to obtain the benefits that should have been paid under the plan, plus possibly attorneys’ fees, and interest. Other remedies, such as punitive damages, make-whole damages, bad faith damages, or similar remedies are preempted.

Additionally, when reviewing the limited record, courts usually review the decision under an arbitrary and capricious (abuse of discretion) standard of review that is deferential to the decision made by the plan administrator. According to the Supreme Court in Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989), the rule is that courts should review denials of ERISA benefits de novo, but that same decision held that if the parties agree to a deferential standard of review, then courts should apply that standard.  Id. at 115. As a result, most ERISA plans and group insurance policies contain language conferring the deferential standard of review, and that exception has virtually swallowed the default rule.

ERISA applies to almost all disputes over employee benefits offered by private employers.  Any state law claims, such as breach of contract or bad faith, do not apply because the rules under ERISA “shall supersede any and all State laws insofar as they may now or hereafter relate to any employee benefit plan . . . .” 29 U.S.C. § 1144(a).

This means almost all employee benefit plans that provide health insurance, life insurance, long-term disability insurance, or similar benefits are governed by federal ERISA law; however, plans sponsored by governmental employers and churches are not usually governed by ERISA.  29 U.S.C. § 1004(b). If ERISA applies, most claims should be filed in federal court (except for claims that are limited to benefits over which state courts have concurrent jurisdiction), and if a plaintiff files a claim that is properly preempted by ERISA, the defendant may remove the claim to federal court without regard to the well-pled complaint rule (29 U.S.C. § 1132(e)); therefore, ERISA claims are rarely litigated in state court.

In addition to receiving pension payments, when you reach the age of 65, you may qualify for additional benefit programs supported by the government. As with many other benefit programs, your qualifications for these programs will depend on your individual financial situation and the availability of programs in your area. Here is a short list of benefit programs that may benefit you and your family. Our team is always here to help you maximize these benefits and ensure long-lasting security.

• Veterans Health Administration (VHA): Established to fulfill the healthcare needs of those who have served in the U.S. armed forces, the VHA operates a vast network of medical centers, clinics, and other healthcare facilities nationwide. Veterans enrolled in the VHA program have access to a wide range of medical services, including primary care, specialized care, mental health services, rehabilitation, and more.
• Social Security Disability Insurance (SSDI): Social Security Disability Insurance is a federal program designed to provide financial assistance to individuals who are unable to work due to a qualifying disability. To qualify, you must meet the Social Security Administration’s definition of a disability, which generally involves having a condition expected to last at least one year or result in death. The amount of SSDI benefits is based on your work history and earnings and may also qualify you to receive Medicare.
• Supplemental Security Income (SSI): Supplemental Security Income is a federal assistance that provides financial support to elderly, blind, or disabled individuals with limited income and resources. Eligibility for SSI is determined by factors such as your income, assets, and disability status. If you qualify for SSI, you will receive monthly cash payments to help cover basic living expenses, including food, shelter, and clothing.