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If you become disabled from work and you are covered by a disability insurance policy, then you need to read the legal guide published by Phil Tatlow on avvo.com.  Phil will give you tips on how to handle your claim without falling into one of the many traps that can ruin your ERISA disability claim.

1. What is a ERISA disability case?
ERISA stands for Employee Retirement Income Security Act and is a complex body of Federal law that controls disability, life, and accident cases when the insurance policy is part of a group policy offered to employees of a company. Some employees are provided with disability or life insurance policies as part of their job benefits. Other employees are given an opportunity to purchase these policies at work as part of their benefits provided through work. If the disability or life insurance policy was offered at work, it is controlled by Federal law. This is important because there are many deadlines and pitfalls under the ERISA statutes. It is very important to follow any deadlines under the policy and the law, or the employee’s claim can be barred.

2. What should I do if I think that I am disabled?
The first thing to do is to find out if you have a disability policy at work. Go to your Human Resources (HR) department and ask for a copy of your benefits booklet if you were not given one and ask for the disability policy and plan documents. These documents are essential to finding out what coverage you have for disability. Next, you should tell your supervisor that your medical conditions prevent you from working and that you want to file a disability claim. Ask for the claim form and carefully review it and provide a detailed medical history of your condition.

3. Should I go to my own Doctor for my problems, or should I go to the company doctor?
If you have a family physician or treating physician that is friendly to you, it is important to tell the physician about all of your medical conditions as a whole, not just the condition that doctor is treating you for. For example, if the doctor is treating you for a knee injury, but you also have a bad back or a prior surgery to another body part, it is important to put this down on the questionnaires or intake sheets, so the doctor knows all of your conditions. If the doctor is friendly to you, this may be a good one to help you with your claim when it comes time for a medical opinion on whether you are disabled under the policy or plan. If you don’t tell them something bothers you, it won’t be in the medical records, therefore, in the knee example, if it hurts to climb ladders, to squat, to kneel, to climb or walk on uneven surfaces, tell that to the Doctor or the nurse. Some company doctors may not be on your side, so it is better to go to your own doctor for your disability claim.

4. Do I have to talk to the insurance company?
Many times, the insurance company will call you at the beginning of the claim about your condition. You are required to cooperate with the company in the investigation of your claim. Therefore, you should talk to the insurance representative. However, you should make notes after your call about what was discussed in case there is a denial of your claim. It is important to give the insurance representative a complete description of your injuries and medical conditions. If you hurt your back and cannot lift much, give an example of what work duties and activities you cannot do. For example, if you cannot lift over 10 pounds without suffering pain, or you can’t bend over without suffering pain, or you have trouble standing in one place or sitting for extended periods of time, tell the person about these problems. Give an example of why the problem makes you unable to perform your job. If you have to sit all day and can’t do it without severe pain, tell the person about this limitation.

5. What records should I submit on my claim to the insurance company?
You should provide a complete list of physicians and healthcare providers, to the insurance company, who have seen you for your medical condition that causes you disability. If you are being treated for an injury but you have also had other health problems, it is better to tell the company about all your conditions and how they all together cause you to be disabled. If you don’t submit all records and documents to the insurance company, under ERISA Federal law you cannot get new records into the court if the case is denied. If you think the insurance company is not really gathering your records and reviewing them, you should ask your doctors for complete copies of the records and submit them yourself.

6. When should I call an attorney?
If you do not understand your rights or cannot figure out how to fill out the paperwork, call an attorney immediately when you have an ERISA disability claim. It is important to call an attorney that handles ERISA disability cases because the law is complicated, and many attorneys don’t know how ERISA works. If the insurance company denies the claim, call an ERISA attorney right away. They are limited rights to appeal a denial and if you do not follow the time deadlines, this could bar your claim. An attorney must have time to gather all of the records and read the policy, the plan and the records before doing an effective appeal. If you wait until the last minute before an appeal is due, most ERISA attorneys may not take the case because there will not be enough time to gather all of the documents necessary to do an effective job on your case. At the Phillip A. Tatlow Law Firm, we like to have at least 60 to 90 days to investigate the claim and obtain records before doing the appeal.

Additional resources provided by the author.

Phillip A. Tatlow Law Firm has additional information on ERISA and disability law.

If, after reading the guide, you have further questions, please call Phil at (920) 854-3214 (Wisconsin) or (314) 266-2286 (Missouri). 

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