The federal law that controls your work disability benefits was not written to protect you. ERISA is the law that sets the rules for many employee benefit plans, but it also makes disability claims much harder. It can take away your right to a jury trial, limit the money you can recover, and restrict the evidence a judge can review.
Bonnici Law Group helps people across the country fight denied, stopped, or reduced long-term disability benefits through work-based LTD plans. We know how ERISA changes the rules, and we build claims to work within those limits.
Call (619) 259-5199 for a free consultation.
At Bonnici Law Group, APC, your goals are our goals.
Table of contents
- How Bonnici Law Group Builds ERISA Disability Claims
- What Does ERISA Take Away From Disability Claimants?
- Why Does the Standard of Review Matter So Much in ERISA Cases?
- How Does the Insurer's Conflict of Interest Affect an ERISA Case?
- Ask Bonnici Law Group
- Which States Have Banned Discretionary Clauses?
- FAQs for Bonnici Law Group's ERISA Disability Attorneys
- Fight Back Under a System That Favors the Insurer
How Bonnici Law Group Builds ERISA Disability Claims
ERISA cases need a different strategy than regular insurance disputes. Strict claim rules, limited evidence, and the way a judge reviews the case all matter from the start. We use this approach in every ERISA case we handle nationwide.
Appeals Built for Federal Court Review
In most ERISA cases, a federal judge can only review the claim file. That means the judge usually only sees the records, letters, and evidence added during your appeal. That is why our attorneys prepare the appeal as if the case may end up in court.
We start by looking for missing pieces in the medical evidence. We ask treating doctors for detailed reports about what you can and cannot do. If the insurer used doctors who only reviewed records and never examined you, we may help arrange independent evaluations.
Our appeal letters point to the policy, answer each reason for denial, and show how the medical evidence meets the plan's disability rules.
Bonnici Law Group has recovered more than $1 million in denied long-term disability benefits using this approach. We build strong claim files for both insurance review and federal court review.
Past results do not guarantee future outcomes.
Tracking Insurer Rule Violations in Real Time
ERISA gives insurers specific rules they must follow. These rules affect how your claim moves forward. They include:
- Deadlines insurers must follow at each stage
- A duty to explain every reason for a denial
- A duty to give you the full claim file for free
When insurers break these rules, it may affect how closely a judge reviews the denial.
Some federal courts have said serious rule violations can take away the insurer's power to receive special deference. This can lead to what is called de novo review. That means the judge reviews the evidence independently, even if the plan says the insurer gets more power.
Our attorneys track these violations as they happen, so they can be used later if the case goes to court.
Standard of Review Analysis Comes First
Before we build the appeal, we review the full plan document and the plan summary. We check whether the plan gives the insurer extra power, whether state law limits that power, and how a court may review the case.
This review guides the rest of the appeal. It affects the medical evidence we gather and the legal arguments we include.
Clients work directly with their attorney during this process. Most calls are returned within 24 hours. Case Manager Miriam Estrada and our support team help keep the claim moving because ERISA usually gives you only 180 days to appeal.
What Does ERISA Take Away From Disability Claimants?
Many people with work-based long-term disability benefits do not know ERISA controls most parts of their claim. ERISA does more than set filing rules. It takes away legal protections people often have in regular insurance disputes.
The table below shows how a regular insurance claim compares to an ERISA disability claim.
| State Law Insurance Claim | ERISA-Governed Disability Claim | |
|---|---|---|
| Who decides | A jury reviews the evidence | A federal judge usually reviews only the written claim file |
| Evidence at trial | New evidence and witness testimony may be allowed | Review is usually limited to the claim file built during the appeal |
| Punitive damages | May be available if the insurer acted in bad faith | Not available under ERISA |
| Emotional distress damages | May be available as part of the damages | Not available under ERISA |
| Bad faith penalties | Available in many states | Not available under ERISA |
| Available recovery | Benefits owed, plus possible extra damages | Usually limited to unpaid benefits and possible attorney fees |
These limits make the appeal the most important part of the claim. Every important record, letter, and medical opinion must be added before the appeal ends. A federal judge may never see anything left out of the appeal file.
Why Does the Standard of Review Matter So Much in ERISA Cases?
If your ERISA claim goes to federal court, one question can shape the case: how much trust does the judge give the insurer's denial?
This is called the standard of review. It may be the most important issue in your case.
| De Novo Review | Abuse of Discretion Review | |
|---|---|---|
| What happens | The judge reviews the evidence independently and decides whether you are disabled | The judge gives the insurer's decision extra weight unless it was unreasonable or lacked support |
| When it applies | The default ERISA standard under Firestone Tire & Rubber Co. v. Bruch | Applies when the plan gives the insurer power to decide who qualifies for benefits |
| Who it favors | Gives claimants a fairer chance to overturn a denial | Favors the insurer because the court starts by giving its decision extra weight |
| How common | Less common because many insurers add this power to their plans | The standard used in many ERISA disability cases nationwide |
Many major disability insurers add discretionary clauses to their plan documents. They know this gives them an advantage in court. This clause makes it harder for claimants to overturn a denial.
How Does the Insurer's Conflict of Interest Affect an ERISA Case?
The insurer decides whether to pay your claim, but it also saves money when it denies the claim. The U.S. Supreme Court addressed this conflict in Metropolitan Life Insurance Co. v. Glenn. The Court said judges must consider this conflict when reviewing the insurer's decision.
The Glenn ruling does not automatically change the standard of review or cancel a discretionary clause. It simply gives the court another factor to consider.
Under abuse of discretion review, a judge may give less weight to a denial if the insurer showed signs of financial bias. A strong claim file can show how this conflict affected the denial.
Common warning signs include:
- Relying on paid medical reviewers instead of your treating doctors
- Picking facts that help the insurer while ignoring facts that support your claim
- Using surveillance to attack your claim instead of fairly reviewing it
ERISA disability attorneys document these patterns during the appeal so they can be used if the case goes to federal court.
Call Bonnici Law Group at (619) 259-5199 for a free consultation.
Ask Bonnici Law Group
My employer pays disability benefits directly instead of using an insurance company. Does ERISA still apply?
Yes. Self-funded ERISA plans are usually covered by the same federal law as insured plans. But there are important differences. State insurance rules, including bans on discretionary clauses, may not apply to self-funded plans. ERISA can block some state laws that apply to employee benefit plans.
The insurer says my condition is "self-reported" and limited to 24 months of benefits. What does that mean?
Many LTD policies limit benefits for conditions based mostly on symptoms you report yourself. Chronic pain, fibromyalgia, and chronic fatigue syndrome are often treated this way. If medical testing or records support your diagnosis, or if the insurer labeled the condition incorrectly, you may be able to challenge the decision on appeal.
I earned a high income before my disability. Does ERISA limit how much I can recover?
ERISA usually limits recovery to the benefits owed under your plan. That amount is usually a percentage of your former income, up to a monthly limit. Unlike some state law claims, ERISA does not allow punitive damages, emotional distress damages, or other extra payments beyond plan benefits and possible attorney fees.
Which States Have Banned Discretionary Clauses?
Some states have pushed back against the unfairness caused by discretionary clauses. Several states have banned these clauses in disability insurance policies.
When a ban applies, courts may review the insurer's decision independently, even if the plan says otherwise.
California has one of the strongest bans under California Insurance Code § 10110.6. It applies to policies covering California residents, even if the policy was issued somewhere else.
Other states with similar bans include:
- New York
- Illinois
- Texas
- New Jersey
- Michigan
- Connecticut
- Minnesota
- Oregon
- Hawaii
- Idaho
- Indiana
- Kentucky
- Maine
- Maryland
- South Dakota
- Utah
- Vermont
- Washington
- Wyoming
However, these rules are not applied the same way everywhere. Some courts have said ERISA blocks certain state bans in some cases. The ban may not apply to self-funded plans, where the employer pays claims directly instead of buying insurance.
One of the first steps in an ERISA disability case is finding out whether a ban applies.
FAQs for Bonnici Law Group's ERISA Disability Attorneys
Is every work-based disability plan covered by ERISA?
Most work-based LTD plans are covered by ERISA, but there are exceptions. Government plans, some church plans, and plans created only to follow workers' compensation or disability insurance laws may be exempt. Disability policies you buy on your own are usually not covered by ERISA. They are usually controlled by state insurance law.
What happens if the insurer misses an ERISA deadline?
ERISA sets deadlines for disability claims and appeals. For appeals, the insurer usually has 45 days, with one possible 45-day extension. If the insurer misses the deadline without proper notice, the claim may be treated as denied. This may allow you to take the case to federal court.
How long do I have to file a lawsuit after my ERISA appeal is denied?
ERISA does not give one deadline for every lawsuit. The deadline depends on your plan and the law where the lawsuit is filed. Some plans set a deadline as short as one or two years from the denial date. If the plan does not give a deadline, courts usually apply the closest state deadline.
My insurer hired a doctor to examine me and then denied my claim based on that exam. How does that affect an ERISA case?
Medical exams arranged by insurers are common in ERISA disability claims. The insurer chooses and pays the examiner. If the exam disagrees with your treating doctor, the appeal must explain why. If the insurer relies on its paid examiner instead of your treating doctors, that may help show the denial was unreasonable.
Does filing for SSDI help or hurt my ERISA disability claim?
An SSDI approval may help your ERISA claim because Social Security made its own disability decision. But SSDI approval may also reduce your monthly LTD payment because of offset rules. Both claims must be handled carefully because each one can affect the other.
Fight Back Under a System That Favors the Insurer
ERISA was not written to help disability claimants win. The system often favors the insurers that manage work-based disability plans. To win, you need to understand those limits and build the right strategy from day one.
Bonnici Law Group's ERISA disability lawyers represent claimants nationwide. Our team builds strong claim files for federal court, tracks insurer rule violations, and fights for every dollar your plan owes.
Call Bonnici Law Group today at (619) 259-5199 for a free consultation.