If your disability insurance claim has been denied or your benefits have been cut off, one of the most important questions is what kind of policy you have. In California, disability claims generally fall into two categories: claims under an employee-sponsored group disability plan, which are usually governed by a federal law called ERISA, and claims under an individual disability insurance policy, which are governed by California state law. The difference between these two types of claims can dramatically affect your rights, your chances of success, and the power an insurance company has over your case.
Certain states, like California, have laws that provide important protections, which can level the playing field—especially in certain ERISA cases—but these protections only apply if your claim is handled correctly from the start.
Group Disability Plans Governed by ERISA
Most disability benefits provided through private employers are part of a group disability plan governed by the Employee Retirement Income Security Act of 1974, commonly known as ERISA. ERISA establishes strict rules for how claims must be handled and how disputes are resolved. Although ERISA was intended to protect employees, it often makes it more difficult to win disability claims.
Under ERISA, disability disputes are decided by a federal district court judge instead of a jury. The court’s review is typically limited to what is called the “administrative record.” The administrative record is the complete paper file that the insurance company created while deciding the claim, including all the evidence the claimant submitted and the documents the insurer generated and relied on to deny or terminate benefits. In an ERISA disability case, the administrative record is the only evidence the court typically sees, which is why it’s so important to submit all supporting evidence during the claim and appeal process.
This means that if important medical records, doctor’s opinions, or vocational evidence are not provided at the appropriate time, they may never be considered later. ERISA also restricts what a claimant can recover. Even if the insurance company acts unreasonably, ERISA generally only allows recovery of unpaid benefits and possibly attorney’s fees, not compensation for emotional distress or bad-faith conduct.
How California Law Levels the Playing Field in ERISA Disability Claims
For many years, ERISA claims were even more difficult because disability policies often gave insurance companies “discretionary authority” to decide whether someone qualified for benefits. When this language was included in a policy, courts were required to give deference to the insurer’s decision, making it far easier for insurance companies to deny claims.
California changed that with the enactment of Insurance Code § 10110.6, effective January 1, 2012. This section of the code makes discretionary authority clauses illegal in disability and life insurance policies issued or renewed in California. When this law applies, courts must review the claim de novo, meaning the court examines the evidence independently without giving deference to the insurance company’s decision.
This protection can be a game-changer for employees in California, or any other state that has a ban on discretionary authority. Without discretionary authority, insurers must justify their decisions based on the evidence rather than relying on judicial deference. Federal courts in California have repeatedly enforced this law in ERISA cases involving California-issued policies. See, e.g., Orzechowski v. Boeing Co. Non-Union Long-Term Disability Plan, 856 F.3d 686 (9th Cir. 2017).
However, not every ERISA claim automatically benefits from §10110.6. Whether the law applies depends on where the policy was issued or renewed and how the plan is structured. Identifying and asserting this protection early can make a decisive difference.
Individual Disability Insurance Policies Under California State Law
Individual disability insurance policies are governed entirely by state law and provide even stronger protections for policyholders. These policies are purchased directly by the insured and are not subject to ERISA’s restrictions.
In California, courts interpret insurance policies under well-established rules that require ambiguous terms to be interpreted in favor of coverage. Courts generally interpret the coverage clauses of insurance policies broadly, protecting the objectively reasonable expectations of the insured (See AIU Ins. Co. v. Superior Court, 51 Cal. 3d 807) Policyholders typically have the right to a jury trial and full discovery, allowing them to uncover how the insurance company actually handled the claim.
Most importantly, California law recognizes that insurers owe their policyholders a duty of good faith and fair dealing. When an insurance company unreasonably delays, denies, or terminates disability benefits, it may be held liable for insurance bad faith. This can include recovery of emotional distress damages and, in appropriate cases, punitive damages. (See Gruenberg v. Aetna Ins. Co., 9 Cal. 3d 566 (1973).
Why This Distinction Matters for California Claimants
Whether your claim is governed by ERISA or state law affects nearly every aspect of your case, including how evidence must be submitted, how the court reviews the insurer’s decision, whether you have a jury, and what damages may be available. Even within ERISA, states like California have enacted bans on discretionary authority under Insurance Code §10110.6, which can significantly improve the insured’s chances—if it is properly applied.
Insurance companies understand these rules and design their claims processes to protect themselves. Claimants who do not understand which laws apply often lose rights without realizing it.
A Strong Advocate for California Disability Claimants
At the Law Offices of Kevin M. Zietz, PC, we focus on representing disabled individuals in complex disability insurance claims, including ERISA-governed group plans and individual disability policies governed by California law. We understand how insurance companies operate, how ERISA limits claimants’ rights, and how California laws—such as Insurance Code §10110.6—can be used to level the playing field.
If your disability claim has been denied, delayed, or terminated, do not assume the insurance company got it right. The steps you take now can determine whether you ever receive the benefits you paid for.
Contact the Law Offices of Kevin M. Zietz, PC today for a consultation. We can review your policy, explain which laws apply to your claim, and help you take informed action to protect your rights and pursue the disability benefits you deserve.
It may seem tempting to appeal a long-term disability claim decision without legal assistance, but doing so can have lasting consequences. Appealing involves more than filling out paperwork or telling your story; it’s a legal process that requires strategy, a thorough understanding of disability policies, medical evidence, and experience with how insurance companies operate.
If you’re facing a denied long-term disability claim, an experienced disability lawyer can be the difference between another rejection and getting the benefits you’re rightfully owed.
What to Know About Long-Term Disability Denials
Long-term disability insurance is designed to protect your income when a health condition prevents you from working full-time. Despite paying premiums for years, claimants often find themselves unfairly denied coverage.
Insurance companies may base their denials on reasons such as:
- Lack of sufficient medical documentation
- Claims that you don’t meet the policy’s definition of “disability”
- Disagreements between your doctor and the insurer’s medical reviewers
- Alleged “pre-existing condition” exclusions
- Missed deadlines or incomplete paperwork
It’s essential to recognize that insurance companies don’t profit by approving long-term disability claims. Their interests are not aligned with yours, and their decisions are often crafted to protect their own well-being rather than yours.
What’s at Stake in Your Long-Term Disability Appeal?
If your initial claim is denied, you typically have the right to file an administrative appeal, especially if your LTD policy is governed by the federal law known as ERISA (Employee Retirement Income Security Act).
This appeal is your first and sometimes only chance to build a complete record for your case. That’s because, under ERISA, once the administrative appeal process is over, your legal rights change significantly; you can file a lawsuit in federal court.
Without a long-term disability claim lawyer guiding your appeal, you risk submitting an incomplete or unpersuasive file, closing the door on vital legal arguments later.
Why Legal Representation Is Crucial at the Appeal Stage
You Need to Strengthen the Administrative Record
Insurance carriers often deny LTD benefits due to a perceived lack of medical evidence. A long-term disability lawyer will work with your treating physicians to prepare detailed medical statements, request relevant records, and ensure all functional limitations are clearly documented. Lawyers know what insurance companies look for and what federal courts expect to see.
Strict ERISA Rules
The ERISA appeals process is filled with strict deadlines and procedural rules. Miss one, and your appeal could be dismissed. A long-term disability claim lawyer will ensure every step is completed on time and in compliance with ERISA requirements. They can also challenge procedural errors made by the insurer during the initial denial.
Understanding the Policy Language Is Key
LTD policies are notoriously difficult to interpret. They often include terms such as “own occupation,” “any occupation,” “regular care,” or “objective evidence,” and their meanings aren’t always clear. A long-term disability lawyer will interpret the policy language in your favor and argue that your condition meets the plan’s definition of disability.
Doctors Don’t Always Know How to Write a Supportive Report
It’s common for treating doctors to undermine a patient’s case unknowingly. They may omit crucial details about your functional limitations, use vague language, or fail to address key aspects of your daily limitations. A lawyer can guide your doctor through the process, helping them prepare letters that meet insurer expectations and hold up under scrutiny.
Appeals Involve Legal and Medical Strategy
An effective appeal weaves together medical records, policy language, and legal arguments into a compelling case. It’s not just about proving you’re disabled; it’s about proving that the insurance company had no reasonable basis to deny your claim. That requires strategy and experience.
Common Mistakes People Make Without a Lawyer
When individuals try to appeal a long-term disability decision on their own, they often make critical errors that weaken their case:
- Failing to request a complete copy of the claim file and policy
- Not submitting updated or supporting medical records
- Writing personal narratives without evidentiary support
- Relying too heavily on emotional pleas rather than legal standards
- Missing deadlines or using the wrong appeal procedures
- Not addressing the specific reasons listed in the denial letter
These mistakes may seem small, but they can be fatal to your appeal.
ERISA-Governed Policies vs. Individual Policies
It’s important to know whether ERISA governs your LTD policy or is a private individual policy. Group plans offered by employers are ERISA-governed, while individually purchased plans are not. A qualified long-term disability claim lawyer can identify the governing law and tailor your appeal strategy accordingly.
When to Call a Long-Term Disability Lawyer
You should consult a disability lawyer as soon as your LTD claim is denied. The clock starts ticking immediately, giving you only 180 days to appeal. Waiting too long or submitting an incomplete appeal could cost you the benefits you deserve.
Your long-term disability lawyer will:
- Collect medical evidence and secure expert opinions
- Draft legal arguments tailored to your policy and circumstances
- Identify procedural errors that could invalidate the denial
- Communicate with the insurance company on your behalf
- Prepare your case for litigation, if necessary
Don’t let a denial letter stop you from getting the support you’re entitled to. If you’ve received a denial and need help with your appeal to a long-term disability decision, reach out to a long-term disability lawyer in California who can stand up to the insurance company and protect your rights.
At The Law Offices of Kevin M. Zietz, our attorney is equipped to handle disability claim appeals without legal fees until you get your benefits. We handle long-term disability claims and appeals and understand how to work with both group and individual LTD policies. Contact us today to schedule a free consultation and get started on your appeal as soon as possible.
