doctorMy private disability insurance policy from my former employer finally approved my long term disability payments.  The Social Security Administration, SSA, approved my disability coverage six months ago and ruled “disabled without hope for improvement.”  This means that SSA will not need to reevaluate my disability for five to seven years. After receiving one monthly payment from the private insurance, I received a call from their representative that I will need to be reevaluated due to criteria changes.  It is a wonder that I didn’t have a stroke right then.  I know my blood pressure must have been elevated because smoke was coming out my ears.

I don’t understand insurance companies.  Disability insurance is gambling, period.  The insurance companies are betting that you will not be disabled before reaching retirement at 65.  You are betting that you will be disabled.  In my case, I won the wager, but I have to prove that I won.  Unlike bookies that pay out winnings, insurance companies do not simply pay out winnings.  You must prove you won and guess who decides whether you proved it.  That’s right.  It’s the insurance company.  Even the law is on the side of insurance.

The Employee Retirement Income Security Act, ERISA, was passed by the U.S. Congress in 1974 and applies to most insurance obtained as an employee benefit. According to the website of Pillsbury & Levinson, LLP, ERISA is one of the worst and most poorly understood laws ever passed by Congress. ERISA gives insurance companies enormous advantages that may actually encourage them to deny claims unfairly.  It would appear there are no penalties for the insurance companies that deny benefits.  After 2 years, I am finally approved but must be re-evaluated because they changed their criteria.  The insurance companies can decide to change the requirements for disability at any time without notice to you.

US SenateUnder ERISA, a policyholder may NOT sue an insurance company for any damages caused by the wrongful denial of benefits no matter how egregious, outrageous, or malicious is the conduct of the insurance company.  Under ERISA there cannot be a jury trial, the policyholder must sue in federal court and there is no pretrial discovery.  If you sue the insurance company, under ERISA it must be filed in federal court and heard by a federal judge.  I had to go through this process in order to received short term disability from the same company that is providing long term benefits.  You do not get damages for the time without an income or the cost of filing the law suit.

ERISA covers retirement, health and other welfare benefit plans (e.g., life, disability and apprenticeship plans). Among other things, ERISA provides that those individuals who manage plans must meet certain standards of conduct,  detailed provisions for reporting to the government and disclosure to participants, assuring that plan funds are protected and that participants who qualify receive their benefits. As pointed out above, this law actually encourages abuse by insurance companies instead of assuring that qualified individuals receive benefits.

ERISA has also been expanded to include new health laws. The Affordable Care Act addressed pre-existing conditions, coverage of adult children, and other protections to ensure affordable health coverage for all.  The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) amended ERISA to provide for the continuation of health care coverage for employees and their beneficiaries (for a limited period of time) if certain events would otherwise result in a reduction in benefits.  The Health Insurance Portability and Accountability Act of 1996 (HIPAA) amended ERISA to make health care coverage more portable and secure for employees.

Wet cat

My benefits were reduced by the amount of my Social Security Act Disability funds so the amount to be paid by the insurance company is rather small.  They are supposed to pay for about eight years.  It appears that the eight years will consist of constant harassment, evaluations, and forms.  My employer paid for this benefit, but I wonder if the harassment will be worth it.

The really bad thing is that there isn’t a thing I can do about it. We are always told these laws are to protect us, but who do they actually protect!

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