Imagine relying on long-term disability (LTD) benefits to cover your expenses and stay financially stable, only to see those benefits suddenly cut off after two years—not due to recovery, but because your condition is considered a mental illness. This situation is a frequent and very frustrating experience for claimants under employer-sponsored disability plans regulated by the Employee Retirement Income Security Act of 1974 (ERISA).
Most group LTD plans include a limit that restricts benefits for psychiatric and nervous conditions to 24 months. This can lead to significant financial hardship for those still unable to work but are cut off because of their condition’s classification. This article aims to clarify how this rule functions, its purpose, and how claimants can recognize important exceptions to safeguard their rights.
What Is the Two-Year Mental Health Limitation?
Most ERISA-governed LTD policies include a “Mental Illness Limitation” (also called a “mental/nervous” clause), which caps benefits for specific conditions at 24 months. This cap applies even if the claimant still qualifies as disabled under the policy’s definition. In contrast, physical disabilities—such as orthopedic injuries or chronic illnesses—are often covered for much longer periods, sometimes until retirement age.
Common conditions typically subject to this limitation include:
- Major depressive disorder
- Generalized anxiety disorder
- Panic disorder
- Post-traumatic stress disorder (PTSD)
- Bipolar disorder
The key issue is not whether the condition is disabling, but whether it falls within the policy’s definition of a “mental illness.”
ERISA and the Lack of Federal Parity
ERISA is the federal law that governs most employer-sponsored benefit plans, including long-term disability (LTD) insurance. While ERISA establishes procedures for claims and appeals, it allows insurers significant flexibility in defining the scope of coverage.
A common misunderstanding concerns mental health parity laws. The Mental Health Parity and Addiction Equity Act (MHPAEA) mandates equal coverage for mental and physical health treatment, but this applies only to health insurance, not disability insurance. As a result:
- LTD insurers are legally permitted to impose a 24-month cap on mental health conditions
- There is no federal requirement that disability benefits be equal for mental and physical conditions
- The limitation is generally enforceable, even if it appears inequitable
Crucial Exceptions to the Two-Year Cap
While the 24-month limit is common, it is not always fixed. Several policies include exceptions that may allow benefits to continue beyond two years under certain conditions.
A notable exception pertains to organic brain disorders or neurological diseases. These are generally classified as physical rather than psychiatric conditions and might not fall under the restriction. Examples include:
- Alzheimer’s disease
- Dementia
- Parkinson’s disease
- Traumatic brain injury (TBI)
Another possible exception involves claimants undergoing inpatient psychiatric treatment when the benefit limit is reached. Some policies permit benefits to continue while the claimant stays hospitalized or in intensive care, although these provisions are typically narrowly defined.
A particularly important exception applies when the claimant has both mental and physical impairments. In these cases, benefits may continue if the physical condition alone is sufficient to prevent the claimant from working. Key considerations include:
- Whether the physical condition is independently disabling
- Whether the claimant would still be unable to work absent the mental condition
- How the insurer characterizes the primary cause of disability
Insurer Tactics and “Catch-22s”
Insurance companies often adopt aggressive stances when enforcing mental health limitations, frequently trying to categorize claims to minimize their financial liability.
A common tactic is over-classification, where insurers stress psychological elements of a condition to keep the claim within the limitation. For example:
- A neurological condition may be reframed as depression or anxiety
- Cognitive impairments may be labeled as psychiatric rather than organic
Another challenge is differentiating between physical causes and mental symptoms. For example, a claimant with a traumatic brain injury might have depression, memory loss, and behavioral changes. However, the insurer may concentrate on the psychiatric symptoms instead of addressing the root brain injury.
Insurers often depend on what is known as the “subjective symptom trap.” Since mental health conditions usually lack objective lab results, insurers might claim that:
- The condition is based primarily on self-reported symptoms
- There is insufficient objective evidence of disability
- The claim falls under additional limitations related to subjective complaints
These strategies can create a difficult evidentiary burden for claimants.
How to Fight the Limitation
Despite these obstacles, claimants still have alternatives. Effectively contesting a mental health restriction usually demands a proactive and strategic approach.
First, it is crucial to thoroughly review the policy language, especially the Summary Plan Description (SPD). Important provisions to consider include:
- How “mental illness” is defined
- Whether neurological conditions are excluded from the limitation
- Any exceptions or extensions that may apply
Second, strong medical documentation is critical. This may include:
- Consistent treatment records from qualified providers
- Opinions from specialists, such as neurologists or psychiatrists
- Neuropsychological testing to assess cognitive impairment
- Imaging studies that demonstrate a physical or neurological basis for symptoms
Third, claimants should approach the ERISA appeals process with seriousness. When benefits are cut off, the administrative appeal may be the sole chance to present further evidence. Key considerations are:
- Courts generally limit their review to the administrative record
- New evidence may not be considered after the appeal stage
- A well-developed appeal can significantly impact the outcome of the case
Finally, seeking legal counsel early in the process can be critical. An experienced ERISA attorney can:
- Analyze the policy for applicable exceptions
- Develop a strategy to challenge the insurer’s classification of the condition
- Ensure that all necessary evidence is submitted during the appeal
- Position the case for potential litigation if needed
Conclusion
The 24-month mental health limitation in ERISA-governed LTD plans is a major and often misunderstood obstacle to long-term financial stability. Although it can lead to the end of benefits for those who continue to be disabled, it is not necessarily the final decision.
Claimants who understand their policy, identify potential exceptions, and establish a solid evidentiary record might be able to extend their benefits or effectively contest the limitation.
If you’re approaching two years or have been notified that your benefits will end, it’s crucial to act promptly. Reach out to our firm for a thorough review of your LTD policy and claim to check if the limitation has been correctly enforced and to explore your available options to safeguard your rights.
If your long-term disability (LTD) claim has been denied because of a “pre-existing condition,” you’re not alone. These clauses are one of the most common—and most misunderstood—reasons insurance companies deny otherwise valid disability claims. For employees covered under group LTD policies through their employer, understanding how these provisions work is critical.
This article breaks down why pre-existing condition clauses exist, how they operate, what triggers an investigation, and when they do—and do not—apply.
Why Do Pre-Existing Condition Clauses Exist?
Insurance companies include pre-existing condition clauses in group LTD policies to manage risk and prevent what is known as “adverse selection.”
In simple terms, insurers want to avoid situations where:
- An employee enrolls in coverage after already knowing they have a serious medical condition, and
- Then immediately files a disability claim based on that condition.
Because group LTD policies are often offered without medical underwriting (i.e., no individual health exam or screening), insurers rely on pre-existing condition limitations as a safeguard.
How Pre-Existing Condition Clauses Work
While the exact wording varies by policy, most group LTD plans follow a similar structure:
1. The “Look-Back Period”
This is typically 12 months prior to the effective date of coverage.
During this period, the insurer looks to see whether you:
- Received medical treatment
- Sought medical advice
- Took prescribed medication
- Had symptoms that would reasonably cause someone to seek care
2. The “Exclusion Period”
Usually the first 12 to 24 months after coverage begins.
If you become disabled during this time due to a condition that falls within the look-back period, benefits may be denied.
3. The Key Trigger
A claim may be excluded if:
- The disabling condition is the same as, or related to, a condition for which you received treatment during the look-back period, and
- The disability occurs within the exclusion period.
What Triggers a Pre-Existing Condition Investigation?
Insurance companies typically investigate pre-existing conditions when:
- A claim is filed shortly after coverage begins (often within the first year)
- Medical records suggest a history of similar symptoms or diagnoses
- There is a gap between employment start date and claim date
- The condition is chronic or progressive (e.g., degenerative disc disease, autoimmune disorders)
Once triggered, the insurer will request:
- Medical records going back 1–2 years before coverage
- Pharmacy records
- Physician notes and diagnostic reports
Examples: When a Claim May Be Excluded
Example 1: Back Injury / Degenerative Condition
An employee begins LTD coverage in January. In March, they file a claim for disability due to severe back pain. Medical records show:
- Treatment for chronic lower back pain in the prior year
- MRI findings of degenerative disc disease before coverage began
Result: Likely excluded as a pre-existing condition.
Example 2: Mental Health Condition
An employee becomes disabled due to major depression six months after coverage begins. Records show:
- Prescription antidepressants and therapy sessions during the look-back period
Result: Claim may be denied based on a pre-existing condition.
Example 3: Cardiac Condition
An employee suffers a heart attack within 8 months of coverage. Prior records show:
- Treatment for hypertension and chest pain during the look-back period
Result: Insurer may argue the heart condition was pre-existing.
Example: When a Pre-Existing Condition Clause Should NOT Apply
Example: New, Unrelated Condition
An employee had treatment for migraines during the look-back period. After coverage begins, they become disabled due to:
- A traumatic knee injury from an accident
There is no medical relationship between the migraines and the knee injury.
Result: The pre-existing condition clause should not apply, and the claim should be covered.
Important Nuances That Often Matter
- “Relatedness” is frequently disputed: Insurers may stretch to argue that two conditions are related when they are not.
- Symptoms vs. diagnosis: Even if no formal diagnosis existed, insurers may rely on prior symptoms.
- Policy language controls: Small wording differences can significantly affect the outcome.
- ERISA governs most group LTD claims: This means strict deadlines and limited opportunities to introduce new evidence after a denial.
What to Do If Your Claim Was Denied
A denial based on a pre-existing condition clause is not the end of the road. These denials are often challengeable—especially where:
- The insurer overreaches in claiming conditions are “related”
- The medical evidence is incomplete or misinterpreted
- The policy language is applied incorrectly
If your group long-term disability claim has been denied due to a pre-existing condition clause, it is critical to act quickly. The appeal process—especially under ERISA—is your best opportunity to build the record and overturn the denial.
We help individuals challenge wrongful disability denials and navigate the complex intersection of medical evidence and insurance policy language.
Contact our office today for a consultation to evaluate your claim and determine the strongest path forward.
Certain medical conditions can prevent a person from maintaining steady employment, making long-term disability benefits an essential form of financial protection. Understanding which conditions meet insurance and legal standards is the first step.
A long-term disability claim attorney can support the claim process and make a meaningful difference in securing those benefits. The Law Offices of Kevin M. Zietz represents individuals across California whose disabling conditions interfere with their ability to work and who need guidance through the long-term disability claims process.
Insurance Coverage for Long-Term Disability
Long-term disability insurance is designed to replace a portion of a worker’s income when a medical condition prevents them from performing their job duties.
Coverage typically falls into two categories:
Employer-Sponsored Plans
Most group LTD policies are regulated under ERISA. This federal law establishes strict procedural requirements, including deadlines for filing claims and appeals. It also limits the evidence that can be introduced if a claim proceeds to litigation.
Individual Disability Insurance
Privately purchased individual policies are regulated under California law, including provisions found in the California Insurance Code. These policies may offer more flexibility in pursuing claims, including the ability to present new evidence in court if benefits are denied.
Insurance companies evaluate long-term disability claims based on the policy’s definition of disability. Some policies require that the claimant cannot perform their own occupation, while others require an inability to perform any occupation for which they are reasonably qualified. This distinction often determines whether a medical condition meets the threshold for benefits.
Medical Conditions that Qualify for Long-Term Disability
Not every illness or injury qualifies for LTD benefits. The key question is whether the condition significantly limits a person’s ability to perform work-related tasks on a sustained basis. Below are the primary categories of medical conditions that often qualify for LTD benefits, along with common examples.
Chronic Illnesses
Chronic illnesses often develop over time and may worsen despite treatment. These conditions can interfere with energy levels, mobility, and cognitive function.
- Autoimmune diseases (such as lupus and rheumatoid arthritis)
- Chronic fatigue syndrome and fibromyalgia
- Diabetes (with complications including neuropathy or vision loss)
- Chronic kidney disease
- Heart disease (including congestive heart failure)
These conditions may not always be outwardly visible, but their impact on daily functioning can be substantial.
Severe Injuries
Physical injuries that result in long-term impairment frequently qualify for disability benefits, especially when they prevent a return to prior employment.
- Spinal cord injuries (causing partial or complete paralysis)
- Traumatic brain injuries (TBI) (affecting cognition and memory)
- Multiple fractures or orthopedic injuries (limiting mobility)
- Amputations
- Severe burns (requiring extensive recovery)
In many cases, the lasting effects of these injuries extend beyond the initial recovery period, making sustained employment difficult or impossible.
Mental Health Disorders
Mental health conditions are increasingly recognized in long-term disability claims, although they often face heightened scrutiny from insurers.
- Major depressive disorder
- Generalized anxiety disorder
- Post-traumatic stress disorder (PTSD)
- Bipolar disorder
- Schizophrenia
Under many policies, benefits for mental health conditions may be limited to a specific duration, often 24 months, unless the condition meets certain exceptions.
Neurological Conditions
Neurological disorders affect the brain, spinal cord, and nerves, often leading to progressive limitations.
- Multiple sclerosis (MS)
- Parkinson’s disease
- Epilepsy and seizure disorders
- Alzheimer’s disease and other dementias
- Amyotrophic lateral sclerosis (ALS)
These conditions can impair both physical and cognitive abilities, making them among the most serious qualifying impairments.
Cancer and Related Conditions
Cancer diagnoses often qualify for long-term disability, particularly when treatment or the disease itself limits the ability to work.
- Active cancer undergoing treatment (chemotherapy, radiation)
- Metastatic cancer
- Residual effects of cancer treatment, such as fatigue or cognitive impairment
Even after remission, ongoing symptoms may continue to support a disability claim.
Reasons LTD Claims with Qualified Medical Conditions Get Denied
Even when a claimant has a legitimate medical condition, insurance companies may still deny benefits.
Common reasons for long-term disability claim denial include:
- Insufficient medical evidence: A lack of detailed documentation regarding functional limitations is one of the most frequent reasons for denial.
- Policy exclusions or limitations: Some policies exclude pre-existing conditions or limit benefits for certain diagnoses, particularly mental health disorders.
- Surveillance and social media monitoring: Insurers may use surveillance footage or online activity to argue that a claimant is more capable than reported.
- Failure to meet policy definitions: If a claimant does not meet the specific definition of disability outlined in the policy, benefits may be denied even with a serious condition.
- Missed deadlines: ERISA imposes strict deadlines for filing claims and appeals. Missing these deadlines can result in the loss of benefits.
California law also recognizes insurance bad faith in certain situations involving individual policies. If an insurer unreasonably denies or delays benefits, legal remedies may be available.
Benefits of Hiring a Long-Term Disability Attorney
Filing a long-term disability claim in California involves more than submitting paperwork. Legal representation can play a key role in strengthening the claim and addressing insurer challenges.
- Building a strong administrative record: A long-term disability lawyer ensures that all relevant medical and vocational evidence is included before deadlines expire.
- Interpreting policy language: Insurance policies often contain technical definitions and exclusions. Legal guidance helps clarify how those provisions apply to a specific case.
- Handling appeals: If a claim is denied, the appeal process is critical, especially under ERISA, where it may be the last opportunity to submit evidence.
- Addressing bad faith practices: In cases involving individual policies, legal action may be pursued if the insurer acts unreasonably.
If you are considering legal help, an LTD attorney can help evaluate whether a medical condition meets eligibility requirements and how to proceed with a long-term disability claim.
Consult a Long-Term Disability Attorney for Free
A qualified long-term disability claim supported by strong medical evidence can make the difference between approval and denial. If you or a loved one is facing challenges with long-term disability claims, you may benefit from consulting our disability claims lawyer at The Law Offices of Kevin M. Zietz to explore your options and protect your right to benefits.
A common question we hear from clients is: Can I receive my retirement benefits and long-term disability benefits at the same time? The answer depends on the type of retirement benefit and the terms of the disability plan governed by the Employee Retirement Income Security Act (ERISA). This article explains the key differences between pensions and 401(k) plans and how they may affect LTD benefits.
Understanding the Difference Between a Pension and a 401(k)
Although both are retirement benefits, pensions and 401(k) plans are structured very differently.
Pension (Defined Benefit Plan)
A pension—also called a defined benefit plan—is funded and maintained primarily by an employer. The plan promises employees a specific monthly payment during retirement, usually calculated based on factors such as:
- Years of service
- Salary history
- Age at retirement
Because the employer funds the benefit and guarantees the payment, pensions are often considered income replacement benefits.
401(k) Plan (Defined Contribution Plan)
A 401(k) is a defined contribution retirement plan. Instead of guaranteeing a fixed benefit, the plan allows employees to contribute a portion of their wages to an investment account.
Key characteristics include:
- Contributions usually come from the employee’s salary
- Employers may provide matching contributions
- The employee controls investments
- The account balance depends on contributions and market performance
Unlike pensions, a 401(k) is essentially a savings account for retirement, not a guaranteed income benefit.
Can You Receive Long-Term Disability Benefits and Retirement Benefits at the Same Time?
In many situations, yes. It is often possible to receive both LTD benefits and retirement benefits simultaneously. However, the crucial issue is whether the retirement benefit will reduce (or “offset”) the LTD benefit.
Most group disability policies governed by ERISA include provisions that allow the insurer to reduce LTD payments for certain types of income. These are commonly referred to as “other income benefits.” Whether your retirement benefits affect your disability payments depends on how the plan defines these offset categories.
When a Pension May Offset Long-Term Disability Benefits
In many ERISA-governed disability plans, pension benefits can reduce LTD payments. This usually occurs when:
The Pension Is Funded by the Same Employer
If the pension comes from the same employer that sponsors the disability plan, the insurer may treat those payments as income that replaces wages. As a result, the monthly pension benefit may be deducted from the LTD payment. For example:
- LTD benefit: $3,000 per month
- Pension benefit: $1,000 per month
The LTD carrier may reduce the disability benefit to $2,000 per month.
The Pension Is a Disability Retirement Benefit
Some employees qualify for disability retirement through their employer’s pension plan. When that happens, insurers often treat the disability pension as duplicative income and reduce LTD benefits accordingly.
A Lump-Sum Pension Is Taken
If someone receives a lump-sum pension distribution, many disability plans allow the insurer to prorate the payment over time and treat it as a monthly offset against LTD benefits.
Why 401(k) Benefits Usually Do Not Offset Disability Benefits
In contrast, 401(k) withdrawals typically do not reduce LTD benefits. The main reason is that most disability policies distinguish between:
- Employer-funded retirement income (like pensions), and
- Employee savings plans (like 401(k) accounts).
Because a 401(k) largely consists of the employee’s own contributions and investment earnings, it is generally considered personal savings rather than wage-replacement income.
Many LTD policies specifically exclude the following from offsets:
- 401(k) plans
- Profit-sharing plans
- Thrift savings plans
- IRAs or similar savings accounts
However, every plan is different, and the policy language ultimately controls.
Important Exceptions and Disputes
Although the general rules above apply in many cases, disputes frequently arise in ERISA disability claims involving retirement benefits. Some common issues include:
Ambiguous Plan Language
If the disability policy does not clearly define which retirement benefits count as offsets, courts sometimes interpret the language in favor of the employee.
Rollovers and Retirement Transfers
In some situations, funds from a pension may be rolled over into an IRA or another retirement account. Insurers sometimes attempt to treat these transfers as income even though the employee did not actually receive spendable funds.
Early Retirement Pressure
There have also been cases where disability insurers encouraged or pressured claimants to take early retirement in order to reduce their LTD liability. These situations can create legal disputes under ERISA.
Why the Terms of the Disability Plan Matter
The most important factor in determining whether retirement benefits will affect disability payments is the language of the LTD plan itself. Two disability policies offered by different employers may treat retirement income very differently. Key provisions to review include:
- The definition of “Other Income Benefits”
- Whether the plan offsets retirement benefits you receive
- Whether it offsets benefits you are eligible to receive
- Whether lump-sum payments are prorated
Understanding these provisions can be critical when evaluating a disability claim.
When Legal Help May Be Important
If your long-term disability benefits were reduced or denied because of retirement income, it is important to carefully review the plan documents and the insurer’s reasoning. ERISA disability claims are governed by complex federal rules, and mistakes made during the claim or appeal process can affect your ability to recover benefits. An attorney experienced in ERISA disability litigation can help determine:
- Whether the insurer correctly applied the plan language
- Whether the alleged offset is permitted under the policy
- Whether the denial or reduction of benefits can be challenged
Final Thoughts
Pensions and 401(k) plans both provide retirement security, but they are treated very differently under most ERISA disability plans.
- Pensions, especially those funded by an employer, are often treated as income that can offset long-term disability benefits.
- 401(k) accounts, on the other hand, are usually considered personal retirement savings and typically do not reduce LTD benefits.
Because every disability policy is different, the specific language of the plan controls whether an offset is allowed.
If your disability insurer has reduced or denied your benefits based on a pension or other retirement income, it may be worth having the decision reviewed by an attorney experienced in ERISA disability law.
Denied long-term disability claims often come down to a handful of recurring problems: weak medical proof, a mismatch between the policy’s disability definition and the claimant’s condition, missed deadlines, and insurer arguments about exclusions or ongoing eligibility.
Over 60% of long-term disability claims are denied. When your disability claim is denied, our long-term disability claim attorney at The Law Offices of Kevin M. Zietz can review your claim and help build the kind of record insurers expect to see to receive long-term disability benefits.
Top 6 Reasons Long-Term Disability Claims Are Denied
Long-term disability insurance is private coverage that replaces part of a worker’s income when illness or injury prevents continued work. Policies vary widely, but many divide coverage into group plans offered through an employer and individual policies purchased directly from an insurer.
Here are the top 6 reasons why long-term disability claims are denied:
1. The Policy Definition of Disability Does Not Match the Claim
One of the most common reasons for denied long-term disability claims is failure to satisfy the policy’s definition of disability. Many policies begin with an “own occupation” standard, meaning the claimant must show an inability to perform the substantial duties of their own job. Later, some plans shift to an “any occupation” standard, which is harder to meet because the insurer argues the claimant can still
2. Medical Evidence Is Thin, Inconsistent, or Too General
Insurers routinely deny long-term disability claims because the medical record is incomplete, inconsistent, or too vague. This problem shows up when office notes are sparse, test results are missing, symptoms are described differently from one visit to the next, or the records do not explain how the condition affects work capacity over time. The issue is even sharper with conditions that are real but harder to measure through imaging or lab work alone, such as chronic pain, autoimmune conditions, or some mental health conditions.
3. Deadlines, Forms, and Ongoing Proof Requirements Are Missed
Another frequent reason for denied long-term disability claims is missing a deadline or failing to provide the right forms. California laws state that a disability policy must contain a notice-of-claim provision requiring written notice after the covered loss begins, or as soon thereafter as reasonably possible. Filing deadlines, especially for employer-sponsored plans covered by ERISA, can become a serious issue if a claimant delays reporting the claim, assumes the employer already handled it, or does not realize the policy requires periodic proof of continuing disability.
4. Pre-Existing Condition and Coverage Disputes
Pre-existing condition clauses continue to be a major source of conflict, particularly in group coverage. Usually, a pre-existing condition has a look-back period of 3 months to 1 year before coverage takes effect, then excludes benefits for a set exclusionary period, often 12 to 24 months. Individual policies can involve underwriting issues as well, especially if the insurer later argues the application did not fully disclose prior treatment.
These are highly fact-specific. An insurer may argue that treatment, medication, or physician advice before the effective date places the claim within the exclusion. The claimant, on the other hand, may contend that the disabling condition is different, the look-back window is being stretched too far, or the insurer is reading the exclusion more broadly than the policy permits.
5. Surveillance, Social Media, and Activity-Based Challenges
Insurers don’t rely only on medical records. They also look for statements and/or activities they believe undermine a long-term disability claim. These can include surveillance footage, social media posts, travel, exercise, childcare, household chores, or part-time work.
A short clip of a claimant carrying groceries, driving, or attending an event can become a denial talking point if the carrier says the activity conflicts with reported limitations. These don’t always prove the claimant can sustain full-time work, but it often becomes part of the denial narrative.
The real issue is consistency. A claimant may be able to complete a single task on a good day and still be unable to work eight hours a day, five days a week, with regular attendance and pace.
6. Treatment Gaps and Noncompliance Arguments
Long-term disability carriers also deny claims when they believe the claimant is not following recommended treatment. Missed appointments, long gaps in care, unexplained changes in providers, or refusal of recommended testing may all be used against the claimant.
Sometimes there is a fair explanation, such as side effects, cost barriers, transportation issues, or a physician’s conclusion that additional treatment would not change function. But if that explanation is not documented, the insurer may frame the gap as proof that the condition is not as limiting as claimed.
This is one reason the treating doctor’s role matters so much. The file should explain not only the diagnosis, but also the treatment course, the patient’s response, and why ongoing symptoms continue to block work.
How a Long-Term Disability Attorney Can Help After a Denial
A long-term disability claim denial is often the point where it finally becomes organized. A disability claim lawyer reviews the policy, identifies whether ERISA applies, maps out deadlines, and determines what evidence is missing from the file.
In some cases, the problem is mostly medical and can be addressed with stronger physician statements, functional assessments, or specialty support. In others, the problem is legal, such as the wrong disability definition, an overbroad pre-existing condition argument, or a denial letter that does not fairly explain the insurer’s reasoning.
A long-term disability claim attorney can also help claimants avoid common mistakes after a denial. This includes sending a rushed appeal, ignoring insurer requests, or returning to work without understanding how it affects eligibility.
If your claim was denied: review the denial letter, gather your policy and medical records, and get a long-term disability claim lawyer for help before the next deadline passes. At The Law Offices of Kevin M. Zietz, we’re ready to evaluate the denial, explain your options, and help you prepare and take the next step. Contact us online or call us at 818-981-9200 for a free initial consultation.
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.
