Long Term Disability Denial and Long Term Disability Termination Basics

If you have received a long term disability denial or a long term disability termination of your
benefits, it is important to understand that the claim is likely subject to a federal law known as
ERISA. As applied to long term disability benefit claims, this law can be complex and unforgiving.
You may therefore benefit from some basic information about ERISA long term disability benefits.
If you have a long term disability benefit, it is likely that it is subject to ERISA. We are all
familiar with employers offering health insurance to employees as part of their compensation. Some
employers also offer long term disability. Employee benefits like health insurance, long term
disability, and life insurance are almost always subject to and regulated by the federal Employee
Retirement Income Security Act.
If your employer offered to provide you with long term disability benefits as an employee
benefit, then you are part of a group plan and likely it is subject to ERISA. If, on the other hand,
you have a long term disability policy that you bought directly from an insurer, it is what we could
call an individual policy and likely that the policy is not subject to ERISA, but instead is subject to
state law. To be absolutely sure, you should consult an attorney, as this article is not intended to be
taken as legal advice.
If you received your long term disability benefits through your employer and it is therefore a
‘group plan,’ it is possible that it is nevertheless exempt from ERISA and subject instead to state law,
just like a typical individual policy. If your policy is established or governed by a public employer, or
by a church, it may be exempt from ERISA. If benefits are paid by your employer directly from its
general funds, such a plan may also be exempt, although this exemption almost always pertains to
short term disability policies and not long term disability policies. Again, you should consult an
attorney to determine whether your long term disability benefits are subject to ERISA.
Having covered the exceptions, let’s turn to the basics of dealing with a long term disability denial or
a long term disability benefit termination. If you applied for benefits and were denied, without ever
having received long term benefits, it is known as a benefit denial. If you were receiving benefits,
but were subsequently terminated from benefits, that is a termination of benefits. A denial or
termination may also be referred to as an adverse determination. When a plan administrator makes
an adverse determination, it must provide the claimant with a written or electronic notice of its
adverse determination. This rule can be found in the federal regulations setting forth the claims
procedure for ERISA governed benefits. (See 29 CFR 2560.503-1(g)).
If a “claims examiner” or other representative managing your claim tells you over the telephone or
by email that your claim has been denied or your benefits have been terminated, you should make

sure that they immediately send you a written copy of the adverse benefit determination, preferable
via email or other electronic means, so that you can review it right away. Once you have obtained
and reviewed it, you should contact an attorney who is very experienced and familiar with ERISA
governed long term disability benefits law.
As will be described in detail in subsequent articles, the claims procedures and federal litigation of
final adverse determinations is complex, unforgiving and completely unlike any other kind of
litigation.
An attorney who is not familiar with these rules, and who treats an adverse determination as if it is
simply a state law breach of contract claim, is likely to mishandle the matter to the detriment of the
claimant. A claimant who delays appealing that matter, or who appeals the determination without
consulting an attorney, or obtaining the claim file, or addressing every basis for the determination, or
submitting records and other information to pack the claim with evidence that will prevail in a
federal court action if necessary, or make clear when and how the determination was unreasonable,
and other important steps, is at risk of receiving a final determination of benefits that cannot be
successfully challenged in federal court.