Washington DC ERISA Disability and Offset Provisions

Many people in DC who are counting on long term disability benefits to make ends meet when they become unable to work are worried and confused when they hear about Washington DC ERISA disability and offset provisions. ERISA provisions are supposed to protect workers, and it can seem like offset provisions protect insurance companies rather than workers.

In order to determine whether ERISA violations have occurred in your situation, it may be helpful to review your case with an experienced ERISA lawyer.

Understanding ERISA

ERISA stands for the Employee Retirement Income Security Act of 1974. This federal legislation protects employees by establishing requirements for private employers, insurance companies, and pension plans so that they administer employee benefit plans, including employee healthcare plans, in a responsible manner.

The ERISA requirements apply to benefits such as pension and retirement plans, health and disability insurance, severance plans and other programs offered by employers. Overall, the ERISA laws are intended to ensure that plans are operated in a way that is fair and financially responsible.

With regard to healthcare, plans are required to inform participants about how to file a claim for benefits and must describe the standards participants are required to meet before they qualify for benefits, such as when they are considered “disabled.”

When a Disability Claim is Denied

Because long term disability benefits are paid by insurance companies who seek to keep their costs low, it is quite common for disability benefits claims to be denied the first time around. ERISA requires the insurance company to provide a written or electronic notice giving the reason for denial and the steps to take to appeal the decision.

The approach taken to appeal a denial will vary depending on the reason for the denial, so applicants often choose to work with a lawyer with experience handling disability claims to help ensure that they explore all available options.

One common reason long term disability benefit claims are denied is for lack of sufficient medical evidence of the disability. In that case, it will be necessary to provide additional records, such as a statement from a qualified doctor explaining how the disability renders the applicant unable to perform job duties.

Disability claims are also frequently denied because the reviewer finds that the applicant does not meet the definition of a disability described in the insurance group plan. A knowledgeable attorney can help devise arguments to counter this denial.

Important Facts About Appealing a Disability Decision

There are two critical factors involved in appealing the denial of a disability claim. The first thing to be aware of is that any future appeals will be based on the factual record presented at the first level of appeal, which is usually an administrative hearing. So it is crucial to ensure that all available evidence is prepared and presented at that time because it cannot be introduced later.

The second key factor is the importance of deadlines. Plans governed by ERISA give applicants 180 days to file an appeal and if that deadline is missed, an applicant will lose the opportunity to appeal the decision.

How Offset Provisions Affect Disability Benefits

In many situations when an employee in DC becomes disabled and unable to work, that employee qualifies to receive long term disability benefits from more than one source. Benefits may be payable from Social Security Disability Insurance, private insurance governed by ERISA, workers’ compensation, or other sources.

When that happens, very often the benefits received from one source are reduced or offset by the amount received from another source. ERISA provisions do not specify what insurance companies may take as an offset, so it is important to check the details in the insurance policy to determine whether long term disability benefits will be offset by other income sources.

Learn More About ERISA Disability and Offset Provisions in DC

It can be difficult to understand whether an employee is entitled to receive certain types of disability payments or whether someone who is qualified is receiving the proper amount of disability payments when offsets are factored in. Those who want to know more about how Washington DC ERISA disability and offset provisions affect their personal situation are advised to contact a knowledgeable ERISA lawyer.