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Employee Benefits

Representing clients appealing employee benefit claims.
Advice on New and Pending Disability Claims
Long-Term Disability Insurance
Short-Term Disability Insurance
Health Insurance Claims
Municipal and State Pension Claims
Other ERISA Benefits: Pensions, Severance, Life Insurance

The process of moving from working to disability is disorienting and scary. You are moving from a career that may have been a central part of your self-image, the thing that organized and animated much of your life, and you have to give it up. And the well-being of the most important part of your life, your family, will depend on successfully navigating this process.

The process is not always easy. You have to fill out forms, knowing they will determine whether or not you will get benefits, but not knowing how they are going to use your answers or what is the best to say. You have doctors who strongly support your disability claim, but do your doctors really know what is best to say to get you benefits? The insurance company representatives asking you questions are incredibly polite and nice, but you know they are looking out for their employer’s interests, not yours. What if you have a condition, like migraine headaches, fibromyalgia or back pain, that you know insurance companies are skeptical about?

Even after you have been awarded benefits, you have to confront these same issues in the yearly requests for statements from you and your doctors about your continuing impairments. Medical conditions change over time, and the applicable standard of disability may change from an own occupation to an any occupation standard. A treating physician’s statement that was sufficient at one time may no longer be appropriate.

You don’t need to navigate this process on your own. In more than thirty years of representing disability claimants, we have learned how to respond to the insurance company’s inquiries and what information to provide to obtain and protect the benefits you are depending on. We consider for each client the client’s occupation, particular medical condition, and the insurance company involved to develop a strategy and a narrative supporting the client’s inability to perform their occupation. This is not work that can be learned in a book. Success in this process is only possible with years of experience dealing with difficult claims and insurance companies, empathetic and patient communication with the client, and relentless attention to the details necessary to support a strong claim.

Long-Term disability benefits are provided by some employers to their eligible employees.  The benefits usually start about six months after a disability occurs, and the benefits can frequently last to one’s regular social security retirement age.  If you don’t know whether you have long-term disability benefits at your employer, ask your employer in writing to provide you with the plan documents and summary plan description of the long- and short-term disability plan, which the employer is required by federal law to provide to you.  The amount of the benefit is generally a percentage of your pre-disability earnings, usually around 60%.

One of the most important issues with long-term disability provided by an employer is that the plan will be governed by the Employee and Income Security Act or ERISA.  ERISA has many special rules that governs all aspects of long-term disability plans provided through employer, from the time frames and processes for applying for benefits, review of claims, internal appeals with the insurer, and ultimately, what claims can be brought in court, and in which court.  Because of these special rules and procedures, there are many traps for those unfamiliar with ERISA long-term disability appeals.  Even good lawyers avoid this area of law.  Navigating filing and managing long-term disability claims, and appeals of long-term disability denials, can be treacherous for non-lawyers.

Another crucial factor in securing long-term disability benefits is knowing what insurers require to establish disabilities resulting from a claimant’s particular condition.  It is counterintuitive that an in-house nurse who works for the insurance company can reject the disability opinion of a highly credentialed physicians who may have treated a patient for decades, but it happens regularly.  Connecticut ERISA attorneys have the benefit of access to a sophisticated local medical community with many national authorities on a wide variety of specialties.  But, a solid opinion by a great doctor may not succeed without the benefit of the knowledge a long-term disability lawyer about what tests, statements, and other proof of disability will satisfy the insurance company.  Please see our blog for discussions of what evidence should be presented to show disability from many of the common conditions involved in insurance company long-term disability denials.  

Short-term disability provides benefits for a short period of time, usually about six months, when long-term disability benefits frequently begin.  Short-term disability and long-term disabilities share many common features that are discussed on our page on long-term disability.  If you have a question about a private disability policy, please go to our page here.

Short-term disability plans do have some unique features:

  • It is more common for short-term disability plans to pay 100% of pre-disability earnings, instead of a percentage like long term disability.  
  • Employers frequently fund short-term disability benefits themselves, rather than through an insurance policy, while hiring an insurance company to make disability determinations.  Because the employer is ultimately funding the benefits, it can have input on the disability determination process and can instruct the insurer to approve the claim.  Part of the strategy to get a short-term disability claim, or to win an appeal, can be to get the employer to support a claim.
  • Some insurers are less rigorous in reviewing claims for short-term disability benefits than long-term claims, though this has changed in recent years.  Since most short-term disability claims provide six months of benefits at best, unlike potentially decades of benefits in a long-term disability claim, we believe some insurers deny solid short-term disability claims and short-term disability appeals because fighting the claim may not be financially worthwhile to fight.
  • A strong application for short-term disability benefits can makes it much more likely that long-term disability benefits will be granted than a short-term disability application that is just good enough.

While short-term disability claims involve less money, they are a crucial bridge to long-term disability and can establish a strong basis for a long-term disability claim.  Having an experienced short-term disability attorney greatly helps to make sure you submit a strong claim, or a strong appeal of a short-term disability denial.

Health insurance is one of most important benefits provided by private employer, important enough that some stay in a job they don’t like to keep their employer-provided health insurance.  Health insurance provided by a private employer is governed, however, by the Employee Retirement and Income Security Act, or ERISA.  That ERISA has many special rules that governs all aspects health insurance plans provided through employer, from the time frames and processes for applying for benefits, review of claims, internal appeals with the insurer, and ultimately, what claims can be brought in court, and in which court.  Because of these special rules and procedures, there are many traps for those unfamiliar with ERISA health insurance claims and appeals of benefit denials.  

Many ERISA health insurance plan participants are surprised when their health insurance claim is denied.  After all, if a doctor says a certain treatment is the best treatment to help you recover, how can the insurance company deny the claim?  The problem is that most ERISA health insurance claims have adopted specific guidelines for treatments, such as residential treatment for eating disorders.  If your claim, or your appeal of a benefit denial, does not address the specific requirements of the treatment protocol that the insurance company will apply, the strongest opinion by the most credentialed doctor is unlikely to succeed.  To win an appeal of a health insurance denial, you need a lawyer who is not only experienced with ERISA, but who is also experienced working with doctors and clients in satisfying the specific requirements of the protocol applied by the insurer.  Connecticut health insurance appeal lawyers have access to a skilled and caring medical profession who can provide, with the guidance of an experienced ERISA benefits appeal lawyer, the support needed to satisfy the obscure criteria applied by health insurers in deciding health insurance benefit claims.

State of Connecticut Pensions

The State of Connecticut offers a wide variety of pension plans to its employees. 

One of the most important pensions is the State of Connecticut disability pensions.  Decisions about whether a disability pension applicant is disabled is made initially by the State of Connecticut Medical Examining Board.  Unlike disability insurance claims, which are frequently made by non-medical claims examiners, all the members of the Medical Examining Board are physicians, so an initial application for a Connecticut disability pension, and any appeal of a denial, must have a strong medical basis.  A Connecticut lawyer experienced with Medical Examining Board appeals can give an applicant for the pension a better chance of prevailing on a claim or appeal.  

The State of Connecticut pension system has multiple tiers, as the State has gradually introduced new pension plans for newer employees, each of which is less generous than the one that came before.  The rules about qualifying for each tier can be complex, and with the right argument based on applying these complex factors, a State of Connecticut may be able to qualify for a more general Tier.   

Connecticut Municipal Pensions

Many municipalities in Connecticut offer pension benefits to their employees.  Some towns participate n the State of Connecticut Municipal Employees Retirement System, which is administered like a State of Connecticut pension, as discuss on this page.  Towns may have more than one pension plan, such as one that covers only the police or fire department.  Every pension plan is different than every other plan.  Some of the plans are decades old and have obsolete or poorly drafted provisions that are difficult to interpret.  Some towns don’t even comply with their plans, administering the pension plan for decades based on past pattern and practice even if it violates the terms of the pension plan document.  Due to sometimes contentious politics, decisions get made because a mayor doesn’t like the person who is apply for a pension rather than in compliance with the plan documents.  Each plan has its own procedures for appeal and failing to follow those procedures exactly can result in a denial of an appeal, or a loss in court, even if the plan provides for benefits.

Most municipal pension plans have special disability pensions available for employees who can no longer do their jobs.  These plans present many of the same challenges as long-term and short-term disability claims, which can be accessed by links on these links.  Since most municipal pension plans lack expertise in assessing the medical information to prove disability, they frequently make poor decisions about medical conditions.  

Because of these factors, in our experience, no other area of employee benefits law involves more irrational and non-plan-based decisions.  Succeeding on an appeal of a municipal pension denial depends on a close technical analysis of the pension documents, and an aggressive pursuit of the benefits in appealing the denial with the plan.  Experience with litigating these types of claims in Connecticut state court is also crucial, as technical rules apply to cases that even lawyers who regularly appear in Connecticut courts may not be familiar with.    

The Employee Retirement and Income Security Act or ERISA covers almost all private employee benefits offered by employers.  Elsewhere on this site we discussed how ERISA covers employer-provided long-term disability benefits, short-term disability benefits and health insurance, but it covers many other benefits as well:

  • Severance benefits.  Some one-time severance plans, like a simple retirement incentive plan, may not be covered, but any sort of continuing plan will be covered.
  • Pension Benefits.  ERISA was passed in 1974 mainly to protect traditional pension benefits, called “defined benefit plans,” that pay a certain amount each month for the retiree’s life.  While private employers have been discontinuing these plans. ERISA still governs the retirement plans employers have established instead such as 401k plans
  • Life Insurance.  

ERISA has many special rules that governs all aspects of the plans that are covered by ERISA, from the time frames and processes for applying for benefits, review of claims, internal appeals with the insurer, and ultimately, what claims can be brought in court, and in which court.  Because of these special rules and procedures, there are many traps for those unfamiliar with ERISA employee benefit appeals.  Even good lawyers avoid this area of law.  Navigating filing and managing ERISA claims, and appeals of ERISA benefit denials, can be treacherous for non-lawyers.  An experienced ERISA employee benefit attorney can be crucial in winning and ERISA benefit appeal or ERISA litigation fighting a denial.  


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