Understanding Your Rights Under ERISA & Disability Law
This page provides general information about ERISA, Social Security Disability, and private disability insurance. These resources are for educational purposes only and do not constitute legal advice. Each case is unique, and we encourage you to schedule a consultation to discuss your specific situation.
The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for retirement and health plans in private industry. ERISA protects employees by requiring plan sponsors to provide participants with plan information, establishing fiduciary responsibilities, and providing access to federal courts if benefits are denied.
ERISA covers most employer-sponsored benefit plans, including:
Government plans, church plans, and plans maintained solely to comply with workers' compensation or unemployment laws are generally not covered by ERISA.
ERISA provides participants with several important rights:
If your ERISA claim is denied, the plan must provide you with a written explanation of the reasons for denial and inform you of your right to appeal. You typically have 180 days to file an appeal. It is critical to exhaust this administrative appeals process before filing suit in federal court. An experienced ERISA attorney can help ensure your appeal includes all necessary medical evidence and legal arguments.
ERISA imposes strict fiduciary duties on those who manage or control plan assets. Fiduciaries must act solely in the interest of plan participants, prudently manage plan assets, follow plan documents, and avoid conflicts of interest. Examples of fiduciary breaches include excessive fees, failure to diversify investments, self-dealing, and misrepresentation of plan benefits.
Social Security Disability Insurance (SSDI) is available to individuals who have worked and paid Social Security taxes for a sufficient period and are now disabled. Benefits are based on your work history and earnings record. Supplemental Security Income (SSI) is a needs-based program for disabled individuals with limited income and resources, regardless of work history.
To qualify for Social Security disability benefits, you must have a medically determinable physical or mental impairment that prevents you from engaging in substantial gainful activity and is expected to last at least 12 months or result in death. The Social Security Administration uses a five-step sequential evaluation process to determine disability.
Step 1: Are you working? If you are earning above the substantial gainful activity level
(currently around $1,550/month for non-blind individuals), you generally will not qualify.
Step 2: Is your condition severe? Your impairment must significantly limit your ability
to perform basic work activities.
Step 3: Does your condition meet or equal a listed impairment? Social Security maintains
a list of impairments considered automatically disabling.
Step 4: Can you do your past work? If you can still perform work you have done in the
past 15 years, you will not qualify.
Step 5: Can you do any other work? Social Security considers your age, education, work
experience, and residual functional capacity to determine if you can adjust to other work.
Most initial disability applications are denied. If your claim is denied, you have 60 days to request reconsideration. If reconsideration is denied, you can request a hearing before an Administrative Law Judge. This is often the most important stage of the process, and representation by an experienced disability attorney can significantly improve your chances of success.
The timeline varies, but initial decisions typically take 3-6 months. If you need to appeal to the reconsideration level, add several more months. Hearings before Administrative Law Judges can take 12-24 months from the request date, depending on the hearing office backlog. If you appeal to the Appeals Council or federal court, the process can extend even longer.
Short-term disability (STD) typically provides benefits for 3-6 months following an illness or injury. Long-term disability (LTD) provides income replacement for extended periods, often until retirement age if you remain disabled. Most employer-sponsored plans require you to exhaust short-term disability before long-term disability begins.
"Own occupation" coverage means you are considered disabled if you cannot perform the material duties of your specific occupation. "Any occupation" coverage is more restrictive, requiring proof that you cannot perform any occupation for which you are reasonably qualified by education, training, or experience. Many policies provide own occupation coverage for 24 months, then switch to any occupation coverage.
Insurance companies deny disability claims for various reasons, including insufficient medical evidence, lack of objective findings, surveillance evidence contradicting claimed limitations, failure to attend independent medical examinations, and pre-existing condition exclusions. Understanding the specific reason for denial is critical to preparing an effective appeal. Our firm analyzes denial letters, obtains additional medical evidence, and challenges improper bases for denial.
An independent medical examination is an examination by a physician chosen and paid for by the insurance company to evaluate your medical condition. Despite the name, these examinations are often not truly "independent" and may be used to support a denial of benefits. You should attend scheduled IMEs but understand that the examining physician works for the insurance company, not for you.
Many disability policies contain offset provisions that reduce your benefit if you receive income from other sources, such as Social Security Disability, workers' compensation, pension payments, or earnings from other employment. Understanding these offset provisions is important, and disputes sometimes arise over how offsets are calculated or whether they apply to specific types of income.
Official DOL website with ERISA information, FAQs, and compliance guidance.
Visit DOL Website →Apply for disability benefits, check application status, and access disability resources.
Visit SSA Website →Information about tax-qualified retirement plans and IRS compliance requirements.
Visit IRS Website →Federal agency that insures private-sector defined benefit pension plans.
Visit PBGC Website →The information on this page is general in nature and is not intended as legal advice. ERISA, Social Security Disability, and private disability insurance law are complex areas with fact-specific rules and procedures. This information should not be relied upon as a substitute for consultation with a qualified attorney who can assess your individual circumstances. For specific legal advice about your case, please contact our office to schedule a consultation.