John B. Dupree, Attorney at Law

Knoxville Lawyer for ERISA Relief

Free Consultation

713 Market Street

2nd Floor - Cate Building

Knoxville, TN 37902

865.437.5081

Entitlement to Benefits

We deal with all kinds of benefits through our office. This includes disability benefits, life insurance benefits, pension benefits, health insurance benefits, special accident benefits and much more. All of these benefits are controlled by the terms of a policy. Typically, these policies set forth a procedure for filing the claim, submitting evidence to support the claim and appeal procedures if a claim is denied. You must obtain a copy of the policy if you desire to know precisely how your claim is to proceed – basically, without the policy you will not know the rules of the game. Usually your employer will have a copy of the policy or will be able to tell you where you may obtain a copy of the policy. If your policy was not issued through an employer, then you will have to seek this information directly from your insurance company.

Disability Benefits

Frequently benefit eligibility depends upon whether a claimant is disabled from employment. But do not assume that because you cannot perform your job that you will be paid benefits. Policy terms such as “total disability” and “totally disabled” are terms of art with a long history of interpretation through the courts. In fact, it would be safe to assume that the substantive paragraphs in your policy have been the subject of legal interpretation many times in many different forums through the years. It would also be safe to assume that your policy has been fine-tuned in consideration of those legal opinions and that the tuning was not for your benefit.

The normal disability benefit journey begins with a short-term disability period where you have to be disabled from the job that you were working when your disability began. This typically lasts for a number of weeks and is an employer- paid benefit. Thereafter, long-term disability begins and has two stages of entitlement. Usually there is a “own occupation” period where you would be entitled to benefits if you are unable to perform any of a range of jobs that fall into a broader general occupational field within which you may work given your education and work experience. This period of benefits usually lasts for two years or so long as you are unable to perform a job within your occupational field. After the two years expires, the requirement for benefits will normally change.

After the initial two year period, you will probably be required to show that you are unable to perform each of the material duties of any occupation for which you are suited given your education, training and experience. This is an “any occupation” provision. These benefits usually last until you reach normal retirement age or until your condition improves to the point that you may return to employment in a job suited to your background. During these two benefit periods, your insurance company will probably require you to periodically send in proof of your continuing disability. Usually, the insurance company requires your physician to complete a form and submit it to the company. Stay involved with this process to make sure the forms arrive at the insurance company because you will not want an interruption of your benefits. If you have questions, do not hesitate to inquire with an experienced attorney because the insurance company uses them every day.

Pension Benefits

Pension claims can be just as onerous as disability claims. They are frequently document intensive and driven by the terms of a well-drafted pension plan and savvy pension fiduciaries. The first step is knowing the terms of your pension plan. Hence, you must obtain a copy of your plan in order to be sure that you are getting what you deserve. Your employer should have a copy of the plan or should be able to tell you where to find the plan elsewhere.

Your pension has almost certainly been an important part of your considerations for retirement. While we have encountered some plans that actually wanted to help the pensioner, more frequently plans take just the opposite stance and attempt to find a way to justify a denial. If you are lucky, my firm will never hear from you regarding your pension. However, if you happen to encounter difficulty with your pension, feel free to inquire with our firm.

Life Insurance/Special Accident/Other Benefits

There are many different types of benefits for which you may be eligible, including life insurance and special accident insurance. Essentially, when a claim is filed for life insurance or special accident benefits, the insurance company begins going through a checklist of items that could lead to denial of the claim. For life insurance, a frequent basis for denial is the alleged non-disclosure of a pre-existing disease or condition. For special accident claims, a recurrent basis for denial is that the incident giving rise to the injury or illness did not arise out of an “accident” as it is defined in the policy. Again, there is a whole host of case law interpreting these concepts and they tend to be very fact specific. Hence, it might be advisable to inquire with an attorney who can present your claim in a way that will meet the terms of the policy.

There are many different types of benefits available to employees or others. Without question, your claim for any of these benefits will be controlled by the terms of a written policy. Therefore, if you desire to pursue those benefits, you should secure a copy of the policy. Otherwise, you cannot be entirely sure that you are getting what you paid for and deserve.

Health Insurance Benefits

Health insurance issues are quite common because health insurance claims are made on a more frequent basis than other kinds of claims. Typically, our office will hear from an insured who has a major claim that has been denied – cancer patients, liver patients, heart patients etc…. But the health insurance company also makes money by nitpicking small items over the course of the year. Therefore, we want to encourage you to appeal the denial of your claim, large or small. Ask questions. Send letters. Make telephone calls. Whoever has the most time in your family to pursue these issues should go after the benefits. You must stay organized in your documentation and write down who you spoke to at the insurance company, when you spoke to them, what was discussed and what was to be done as a result of your conversation. Take some time and read your policy and its appeal procedures one evening. Highlight and tab the important things to remember and maybe even set up a flow chart relevant to how an appeal will take place with dates and events denoted accordingly. Challenge yourself to stay ahead of the insurance company on the claim. You will find that it is most satisfying to correct an insurance representative on a factual issue and offer to fax them the proof.

If you find that you need help with your health insurance claim, feel free to send us a contact form or give us a call.

John B. Dupree, Attorney at Law

713 Market Street

2nd Floor - Cate Building

Knoxville, TN 37902

Email: john.dupree@knoxtnlaw.com

865.437.5081 Phone

865.437.5082 Fax

© 2018 John B. Dupree, Attorney at Law. All Rights Reserved.