An ERISA disability lawyer handles disputes between you and an employer-sponsored long-term disability insurance plan
An ERISA long-term disability lawyer represents you when your employer's disability insurance plan denies your claim, stops your benefits, or fails to pay what you believe you are owed. ERISA is the federal law that governs most employer-sponsored disability plans. A lawyer who specializes in this area knows how to read your plan documents, challenge a denial in writing, and file a lawsuit in federal court if the insurance company will not reverse its decision.
This is different from representing you in a Social Security Disability Insurance (SSDI) case. ERISA covers private insurance plans that your employer offers or funds. SSDI is a federal program run by the Social Security Administration. Many people have both types of coverage and may need different lawyers for each.
The core job is to prove that your disability meets the definition in your specific plan and that the insurance company's reason for denying or stopping your benefits does not hold up under the law.
Key Takeaways
- An ERISA disability lawyer reviews your plan documents and the insurance company's denial letter to identify what went wrong with your claim.
- The lawyer sends a formal written appeal to the insurance company, citing plan language and federal law, and requests a written explanation if the company denies the appeal again.
- If the insurance company refuses to pay after appeal, the lawyer can file a lawsuit in federal court on your behalf.
- You typically pay the lawyer only if you win money back, either through settlement or court judgment, because most ERISA cases work on a contingency fee basis.
- The lawyer's job is to challenge the insurance company's decision, not to prove your disability to a government agency.
Reading and interpreting your plan documents
Your disability insurance plan is a contract between your employer (or union) and the insurance company. The plan spells out exactly what "disabled" means, how long you can collect, what you must report, and what the insurance company can ask you to do. Most people never read these documents until a claim is denied.
An ERISA lawyer's first step is to obtain and carefully read your plan. The lawyer looks for the exact definition of disability that applies to you—some plans say you cannot work in your own occupation, others say you cannot work in any occupation. The lawyer also checks what medical evidence the plan requires, what the insurance company is allowed to ask for, and whether the company followed its own rules when it denied you.
If the plan says the insurance company must base its decision on medical records and your own statement, but the company also demanded a functional capacity evaluation that the plan does not mention, that is a violation the lawyer can use in your appeal.
Challenging the insurance company's denial in writing
When an insurance company denies your claim or stops your benefits, it sends you a denial letter. That letter must explain the reason and cite the plan language or medical evidence it relied on. An ERISA lawyer reads this letter as a roadmap to what the company thinks is wrong with your claim.
The lawyer then prepares a detailed written appeal. This appeal is not a restatement of your medical history. Instead, it is a legal argument that points out where the insurance company misread the plan, ignored medical evidence, or applied the wrong standard. For example, if your plan says you are disabled when you cannot work in your own occupation as a nurse, but the company denied you because you could theoretically work as a cashier, the lawyer's appeal will cite that language and explain why the company's reasoning contradicts the plan.
The appeal also includes new medical evidence if you have it—updated doctor's notes, test results, or a statement from your treating physician that directly addresses what the company said was missing. The lawyer knows which evidence matters and how to present it so the insurance company cannot ignore it.
Federal law requires the insurance company to respond to your appeal in writing and to explain its reasoning if it denies the appeal again. If the company straightforward says "we reviewed your appeal and stand by our decision" without explaining why, that is a legal error the lawyer can use in court.
Filing a lawsuit in federal court if the appeal fails
If the insurance company denies your appeal or does not respond within the time the law allows, your lawyer can file a lawsuit in federal court. This is not a trial in front of a jury. ERISA cases are decided by a judge who reviews the written record—your medical records, the plan documents, the denial letter, your appeal, and the company's response.
The lawyer prepares a brief that argues the insurance company's decision was wrong as a matter of law. The insurance company files its own brief defending the denial. The judge then decides whether the company's decision was reasonable and supported by the plan and the medical evidence.
If you win, the judge can order the insurance company to pay your benefits, to pay benefits going forward, and sometimes to pay your lawyer's fees. The insurance company may appeal the judge's decision to a higher court, which extends the timeline but does not change your lawyer's role.
Gathering and organizing medical evidence
Your medical records are the foundation of your case. An ERISA lawyer works with you to collect records from every doctor, therapist, hospital, and clinic you have seen since your disability began. The lawyer also asks you to obtain a detailed statement from your treating physician—the doctor who knows you best and has treated you the longest.
The lawyer reviews these records to find the evidence that supports your claim under your specific plan definition. If your plan requires that you be unable to perform the material duties of your occupation, the lawyer looks for records showing you cannot sit for eight hours, cannot lift more than ten pounds, or cannot concentrate for the time your job requires. The lawyer may also hire a medical informed to review your records and write a report saying your condition meets the plan's definition of disability.
The insurance company will have its own medical informed review your records. That informed may disagree with your doctors. Your lawyer knows how to challenge the insurance company's informed and explain why your treating doctors are more credible.
Negotiating a settlement with the insurance company
Many ERISA cases settle before trial. The insurance company may realize its denial was weak and offer to pay a portion of what you are owed, or to reinstate your benefits for a set period. Your lawyer negotiates on your behalf and advises you whether a settlement offer is fair.
A settlement might mean the insurance company agrees to pay you a lump sum for back benefits, or to resume monthly payments, or both. Your lawyer reviews the offer against what you might win in court, the cost and time of continuing to fight, and the risk that the judge might rule against you.
If you and your lawyer decide to settle, the lawyer drafts the settlement agreement and makes sure it protects you—for example, that the company cannot later claim you admitted fault or that the settlement does not affect your SSDI benefits.
How ERISA lawyers charge for their work
Most ERISA disability lawyers work on a contingency fee basis. This means you pay nothing upfront and the lawyer takes a percentage of the money you recover—usually 25 percent to 33 percent of the back benefits the insurance company pays you. If you do not win money, you do not pay the lawyer's fee.
You may still owe costs, such as the fee for a medical informed's report or the court filing fee. Some lawyers advance these costs and deduct them from your recovery. Others ask you to pay costs as they arise. Ask about this before you hire a lawyer.
Some lawyers charge by the hour instead of contingency. This is less common in ERISA cases but may happen if your case is straightforward or if you are seeking a small amount of money. Hourly rates vary widely by location and the lawyer's experience.
When to contact an ERISA disability lawyer
Contact a lawyer as soon as your claim is denied or your benefits are stopped. The sooner your lawyer reviews your case, the sooner you can file an appeal. There are time limits for appealing—usually 60 to 180 days depending on your plan—and missing the important date can cost you the right to sue.
You should also contact a lawyer if the insurance company asks you to do something unusual, such as submit to a surveillance investigation or a medical exam by a doctor you have never seen. A lawyer can tell you what you are required to do under the plan and what you can refuse.
If you have already appealed on your own and the insurance company denied the appeal, it is not too late to hire a lawyer. The lawyer can still file a lawsuit, though the sooner you act, the better.
Frequently Asked Questions
Can an ERISA lawyer also handle my SSDI case?
Some lawyers handle both ERISA and SSDI cases, but they are different areas of law. Ask the lawyer about their experience with both. You may need two separate lawyers—one for your employer plan and one for Social Security—because the standards for disability are different and the evidence that works in one case may not work in the other.
What if my employer's plan is self-insured instead of insured by an insurance company?
ERISA law applies the same way. Your employer acts as the insurance company and makes the decision to deny or approve your claim. Your lawyer still appeals to your employer and can still sue in federal court if the appeal fails. The process is identical from your perspective.
How long does an ERISA case usually take?
An appeal typically takes two to six months. If the appeal is denied and you file a lawsuit, the case may take one to three years depending on how busy the court is and whether the insurance company appeals the judge's decision. Settlement can happen faster if the company realizes its position is weak.
What happens to my benefits while my case is pending?
If your benefits were stopped, they usually stay stopped until you win your case or reach a settlement. If your benefits are still being paid while you appeal, the insurance company may ask you to repay them if it wins. Ask your lawyer whether you should set aside money for this possibility.
Do I need a lawyer, or can I handle the appeal myself?
You can appeal on your own, but insurance companies deny appeals more often when there is no lawyer involved. A lawyer knows the law, knows what evidence matters, and knows how to write an appeal that the insurance company cannot easily dismiss. The contingency fee means you only pay if you win.