disability benefits

[Guest celliott]

What procedure to follow or what laws help the disabled person to get benefits from insurance company that keeps denying benefits

[QDROphile]

A disability arrangement that is a plan covered by ERISA (not all are) must have a claims procedure, which includes a procedure for review of a denied claim. If a claim is denied, the plan must advise about the procedure for requesting a review of the denial. If the claim is denied after review, recourse is through the courts. If a benefit is impropoerly denied, the claimant may be able to get an award of attorney's fees, but usually only if the plan has been unreasonable. If an insurance company is involved, the state insurance commissioner (or whatever the equivalent may be in a particular state) might be of some assistance in dealing with the insurance company, but that will vary from state to state. Generally, whether or not a person is entitled to benefits depends on the terms of the plan/policy. If the plan/policy does not cover the particular disabilty, no benefits. However, some laws (especially state insurance laws) govern what a plan/policy must provide.

[KIP KRAUS]

I agree with everything that QDROphile has said. In addition, most disability plans require you to be totally disabled (as defined by the the insurance contract). Generally, if yoiu are not totally disabled based on the medical evidence submitted by your attending physician, the insurer will deny coverage. If you have followed all of the claim filing procedures, and have been denied benefits, you should follow the claims review procedures in your Summary Plan Description. If these procedures are not outlined in your SPD, file your written request with the Plan Administrator, which may be your employer.

If you can, without revealing your particular disability, a discription of why your benefits are being denied may help in providing you with additional information.

[Guest MattNewman]

One thought about the above comments on the availability of attorney fees. Some of the jurisdictions might well make it difficult for prevailing plaintiffs to obtain attorney fees in ERISA cases (I've heard District Courts in Florida are difficult to get fees), however, that is not the case with all jurisdictions. For example, in the 8th and 9th Circuits, prevailing plaintiffs are presumptively entitled to an attorney fee award.