ERISA and Long-Term Disability Insurance Claims

If you have had an insurance claim denied, and you received the insurance coverage through your employer, there’s a good chance that the matter is governed by a federal law known as the Employee Retirement Income Security Act (“ERISA”). Many people obtain health, life, disability or similar coverage through benefit plans sponsored by their or their family member’s employer. ERISA typically governs these types of employer-sponsored insurance.

McKean J. Evans and other Ruiz & Smart attorneys have extensive experience in this complex niche of the law. When an insurance claim is denied, ERISA provides important rights, including the right to challenge the denial, obtain evidence from the insurance company, and recover the attorneys’ fees incurred if filing a lawsuit becomes necessary to obtain insurance benefits. ERISA also imposes rules that must be followed in order to protect your rights. ERISA typically requires claimants to meet specific deadlines and provide specific information in support of an insurance claim.

Key features of ERISA you might notice if you receive a letter from an insurance company denying a claim:

• “You have the right to appeal this decision”: ERISA typically requires the insurance company allow you to appeal its decision to deny your claim. This appeal process is critical to protecting your rights under ERISA. Insurers often provide incomplete or confusing information about the appeal process.

• “You do not meet the definition of ‘disabled’” or other insurance policy terms: ERISA cases often turn on the fine print of the insurance policy or employee benefit plan documents.

• “Our independent physician disagrees with your doctor”: In cases involving medical issues such as disability or health insurance, insurers often deny claims relying on reviews from purportedly “independent” physicians. These doctors are sometimes incentivized financially to produce opinions that support denying claims. They often overlook or minimize key evidence.

Ruiz & Smart' attorneys have obtained successful results in cases involving the denial of insurance claims under ERISA-governed insurance policies and employee benefit plans involving some of the largest employers in Washington State. Some of the results in ERISA cases include:

• Chapin v. Prudential Ins. Co. of Am., No. 2:19-cv-01256-RAJ (W.D. Wash.)—obtained judgment in favor of software engineer wrongfully denied Long-Term Disability insurance benefits.

• Bray v. Metro. Life Ins. Co., No. C21-01453-LK (W.D.Wash)—represented tech firm executive who was wrongfully denied Long-Term Disability insurance benefits; the insurer paid the benefits shortly after suit was filed.

• Harrison v. Metro. Life Ins. Co., (W.D. Wash.)—obtained judgment in favor of Long-Term Disability benefit claimant.

• Medical Insurance Coverage Under Microsoft Benefit Plan—Successfully obtained reversal of health plan’s decision to cut off coverage for life-changing medication after a sharp price increase.

• Denial of Long-Term Disability Claim by Standard Insurance Co.—Represented a physician whose disability prevented her from continuing with a highly respected practice.

• Disability Claim for Leading Seattle Surgeon—Successfully represented surgeon in seeking long-term disability benefits, avoiding litigation.

• Improperly Denied Life Insurance Benefits—Represented beneficiaries when an insurance company accepted a premium for a higher benefit but then failed to provide the higher benefit after the insured passed away.

• Appeals of Medical Benefits Denials by Kaiser (Group Health)—Assisted claimants seeking reversals of denials by different health plans, including Group Health (now Kaiser)