Dallas Disability Benefits Attorneys
Dallas, Texas Statewide and Nationwide
Denial of Disability Benefits • Denial of Occupational Injury Benefits
Were you injured at work? Has your injury resulted in a disability? You may be entitled to disability and occupational injury benefits from your employer or its insurer. Texas employment and insurance law and the federal Employee Retirement Income Security Act (ERISA) give rights to employees who are entitled to benefits. At Kilgore + Kilgore we can help ensure that those rights are protected.
Our Dallas disability benefits lawyers have represented and continue to represent clients in the Dallas-Fort Worth area, statewide, and nationwide. Contact Kilgore + Kilgore today for a confidential discussion of your disability benefits or work-related injury case.
“ Bob Goodman took my case when a long-term disability insurance company denied the continuance of my benefits. From our first meeting, I knew I was in good hands. He was thorough in the presentation of my case and . . . got the best settlement. Bob . . . is a man of integrity and . . . represents his client’s best interest.”
Karen, disability benefits case, 2006
Unpaid Short-Term and Long-Term Disability Benefits and Occupational Injury Benefits Due by Employers and Insurers
Our attorneys understand the distinct legal standards applicable to the different disability claims and develop differing strategies and tactics for pursuing and winning cases.
There are five basic types of private disability and occupational benefit claims:
Claims Under Employer Group Plans or Policies
“Thanks again for all your hard work over the last few years on my disability claim denial. I trust you and believe you are a good lawyer. I am glad to have had the privilege of working with you, Bob Goodman.”
- Sarah, Long-Term Disability Matter, 2011
Claims under employer group plans or policies can be difficult to win, especially when a disability claim governed by ERISA has been denied. Retaining an experienced Texas disability benefits lawyer is often necessary to obtain any payment of benefits. Employer group plans are usually insured and administered by insurance carriers, but occasionally are self-insured and administered by a claims administrator, which may or may not be an insurer. Claims under employer group plans are governed by the federal Employee Retirement Income Security Act.
The standard for ERISA claims is "abuse of discretion." This means that the insurance company's decision to deny a claim must have been arbitrary and capricious — not just unreasonable. The only aspect of ERISA that gives individuals a strong argument to challenge denial of a disability benefit claim is the fiduciary duty imposed by ERISA on employers and insurers who decide claims. That duty traditionally requires loyalty and full disclosure, as well as a high degree of intellectual honesty.
In most instances, insurers do not follow ERISA claims procedures, or do so only when it suits them. Of course, no insurers are remotely altruistic, but disability insurers are frequently shameless. This is why retaining counsel is important.
Kilgore + Kilgore has handled many ERISA claims and can help you overcome these hurdles. We will try to stay ahead of the adjusters that disability insurers employ, calling attention to your difficulties in daily life and the insurer's failure to meet its duty as an ERISA fiduciary. We will pursue your claim through multiple levels of review, address any mischievous arguments that the insurer company uses to deny your claim, and coordinate medical and vocational records to prove that the denials were wrong.
This approach often leads to a reversal of a denial of benefits claim and payment for unpaid benefits and, in isolated instances, a lump sum settlement of all or part of the present value of future benefits through the end of the term of benefits.
Insured on the Job Claims
Claims under employer occupational injury benefit plans are also governed by ERISA, under plans adopted by employers as an alternative to obtaining workers’ compensation coverage. The plans are generally administered by an employer, but in a minority of cases, they are administered by an insurer or specialty third-party administrator.
Claims under employer occupational injury benefit plans usually raise issues beyond an employee's disability, such as the timeliness of notice of an injury and the appropriateness of medical expenses for the injury. These plans are almost always oppressive in their one-sidedness. As a result, claims under such plans are often harder to pursue than even group disability benefit plan claims. When claims are successfully pursued, the benefits afforded are in many cases even more limited than workers’ compensation benefits.
No occupational injury benefit plan can prevent a personal injury claim — generally referred to as a “nonsubscriber” claim — against the employer where there is at least an argument that the employer was negligent. Some plans do not disclose the possibility of such claims, while others explicitly recognize the possibility of such claims for the purpose of compelling arbitration. Texas courts have, unfortunately, upheld arbitration stipulations. Sometimes, clients are best advised to not even pursue claims under employer occupational injury benefit plans because of the nearly impossible hurdles to success and limited value of success, but to pursue instead the related nonsubscriber claim either subject to an arbitration provision or not. The standard of liability applicable to nonsubscriber personal injury benefit claims is very favorable to employees.
Claims Under Professional Association Group Plans
Some professional associations, such as the American Institute of Certified Public Accountants, have provided their members the opportunity to purchase disability benefit insurance through a group policy. Claims under professional association group policies may or not be governed by ERISA, depending on various aspects of the organization's relationship to its members and the nature of the policy. If claims under these policies are governed by ERISA, they must be pursued in the same fashion as employer group disability claims.
When they are not, however, insurers cannot defend a denial simply on the basis that it was not an abuse of discretion, but must prove that the denial was justified on its merits. If the decision to deny a claim was not only wrong, but no reasonable insurer would have denied a claim, you may be able to recover lost benefits and interest as well as compensatory damages, attorney's fees, and, in extreme cases, punitive damages.
Pursuing claims under professional association group plans or policies is not as difficult as under ERISA plans or policies, but the mindset of the insurers issuing such plans or policies tends to be as anti-claimant, and slanted toward denial, as under ERISA plans or policies. Accordingly, some of the same bullheadedness is required to pursue these claims as ERISA claims.
Claims Under Individual Disability Policies
Individual disability policies have long been available to certain professionals, physicians, dentists, and lawyers. Sometimes, individuals who are not professionals are prudent enough to purchase their own disability policies. Claims under such policies, like claims under professional association group plans or policies, are generally not governed by ERISA, and so pose the same risk of a bad faith claim accompanied by compensatory and punitive damages.
Because most claimants are professionals and likely to be either legally or medically astute, these claims are subject to favorable resolution to a higher degree than the other three categories of claims. That is not to say, however, that you will not face the same unreasonableness that is common in the employer plan context.
Claims Under Municipal Employer Disability Plans
The law concerning municipal employer disability plans in Texas is sparse, but it appears that such plans are not subject to either ERISA or precluded by sovereign immunity. They, accordingly, afford the same potential for bad faith claims, with accompanying compensatory and punitive damages, as claims under professional association group plans and claims under individual disability policies.
Related Claims
Because of the poor quality of many employer occupational injury benefit plans, it is often most appropriate to recommend pursuit of nonsubscriber personal injury claims to individuals who are entitled to pursue benefits under employer occupational injury plans where such benefits are not adequate.
Other categories of disability and occupational injury claims include:
- ERISA Severance Benefit Claims: These claims are analogous to disability benefit claims but legally distinct. The same is true of disputes relating to the propriety of offset of disability or severance benefits by other types of benefits, such as Social Security retirement benefits or third-party insurance recoveries.
- Workers' Compensation Bad Faith Claims: Under Texas law, insurers must act reasonably in the handling and settlement of claims.
- Disability Discrimination and Retaliation Claims: Under the Americans With Disabilities Act (ADA) and the Texas Labor Code, individuals who have suffered discriminatory or retaliatory treatment in connection with employment or termination of employment have addition claims.
Contact Our Texas Work-Related Injury Lawyers and Disability Benefits Attorneys
Individuals with work-related injuries and disabilities are protected in important ways under a variety of laws, and can be represented by capable and compassionate employment law attorneys of Kilgore + Kilgore. We will explain your rights and advise you on the steps you should take.
Contact Kilgore + Kilgore today to discuss your possible claims for short-term disability benefits, long-term disability benefits, occupational injury benefits, and other claims relating to work-related injuries or disabilities. We are here to help you through the entire process.