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You paid into a long-term disability policy for years. Now the insurer has denied, delayed, or terminated your claim, and the explanation does not match the medical reality you live with every day. Because the coverage came through your job, a federal law shapes how the claim is reviewed, and some of the most common ERISA violations happen during that review. The path forward often runs through the ERISA disability appeals process.
Under that law, the record built during your claim and appeal can close. Once it does, a court generally decides the case on the documents already in the file, so a violation that goes unnoticed can cost you the claim before a judge sees it.
We built our practice around this fight. The Law Office of Justin C. Frankel, P.C., represents professionals nationwide whose long-term disability claims have been denied or terminated under ERISA, and we know where a review can go wrong. We spot violations early, protect the administrative record, and strengthen your appeal within the limits of the rules.
The Employee Retirement Income Security Act of 1974, known as ERISA, sets minimum standards for many private employer-sponsored benefit plans, including most group long-term disability coverage. The U.S. Department of Labor enforces it through the Employee Benefits Security Administration.
ERISA also sets the rules the insurer and plan administrator must follow when they review your claim, decide on an appeal, and build the record. It limits your options in ways an ordinary insurance dispute does not, so knowing whether your plan is governed by ERISA matters before you respond to a denial.
Not every denial involves a violation, but several recurring problems show up when insurers handle ERISA disability claims. Each one can affect whether your record is complete and whether you got the review the law requires.
ERISA entitles you to a full and fair review of a denied claim, with a real chance to see and respond to the evidence behind it before a final decision. A review that rubber-stamps the denial or refuses to engage with new medical proof falls short of that standard.
You are entitled to your claim file and the governing plan documents, the materials the insurer used to decide your claim. Refusing, delaying, or sending an incomplete file leaves you answering a denial you cannot fully see, which makes building an appeal harder.
Insurers often rely on a file-only review by a hired IME medical consultant who never examines you, then treat that opinion as more credible than the doctors who manage your condition. In many cases, the consultant is retained to support a denial, not to understand your daily limitations.
When the same company pays benefits from its own funds and also decides whether your claim qualifies, that structural conflict can shape the outcome and raise a breach of fiduciary duty concern. A reviewer whose employer saves money by denying your claim is not neutral, and courts weigh that conflict when reviewing how a claim was handled.
ERISA lays out a process the insurer must follow, with defined steps for deciding a claim and an appeal. Missing those steps, giving no clear reason for a denial, or letting a decision drift past the plan’s deadlines can each be a violation. The pattern matters more than any single date.
A violation matters because of how ERISA cases are decided. Your initial claim and your appeal make up the administrative stage, where the record is built. Once you exhaust the plan’s appeals and that record closes, a federal court generally reviews what is already in the file rather than holding a new trial, usually with no jury.
That makes each violation costly. A withheld file or a paper review that ignores your treating doctors can leave gaps that are hard to repair later. Recognizing one early gives you room to respond while the record is still open.
If you think a violation has affected your claim, a few steps can protect your position while the record is open.
If the appeal does not resolve the claim, a federal lawsuit may follow, and an ERISA plan sets requirements you must meet before you sue. A lawyer who handles appealing a long-term disability denial early can keep your options open.
Many professionals carry more than one layer of disability coverage. Alongside a group plan from work, you may hold an individual or private policy you bought directly. The distinction matters when a claim goes wrong, because the rules differ.
ERISA usually governs employer-sponsored group plans, while an individual policy you bought on your own generally follows state insurance law. That often means stronger rights, including a standard lawsuit with live testimony rather than a closed-record review. If you hold both, it helps to understand how ERISA and private policies differ before you respond.
No. Proving a violation and proving your disability are two separate tasks. A flawed review does not show that you cannot work, so you still must prove your condition meets the policy’s definition of disability with current medical records, your doctor’s restrictions, and evidence of your limitations.
Yes, once you finish the plan’s required appeal steps. The suit asks a federal judge to review the insurer’s decision, and a court that finds the review flawed can order benefits reinstated or send the claim back for a corrected review.
Sometimes. ERISA gives a federal court discretion to award attorney’s fees to either side in some cases, so a fee award is possible but never promised. Whether fees are awarded depends on the facts and the court’s view of the record.
Spotting a possible ERISA violation in a denied long-term disability claim is the moment to act, while the record is still open. We take on the fight with the insurance company so you can focus on your health. A free consultation can tell you whether a violation affected your claim and what steps remain. Call the Law Office of Justin C. Frankel, P.C. at 888-583-4959 or schedule a free consultation to talk through your options.
Justin C. Frankel is committed to fighting for the rights of clients when their long term disability insurance claims have been denied, delayed or terminated. His entire legal career is focused on representing long term disability insurance policy owners. His clients are treated with the utmost of concern and care during very difficult times.
