Your Policy Is a Contract. Know What It Promises. and What It Takes Away
ERISA vs. Non-ERISA: The Most Important Question You Will Ask
If your disability coverage came through an employer, it is almost certainly governed by the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. §1132. That federal law strips away your right to a jury trial, limits the damages you can recover, and locks you into an administrative record that is nearly impossible to expand later. Individual policies purchased directly — not through an employer — are governed by state law and carry broader protections. Knowing which world you are in shapes every decision we make for you from day one.
What you need to know
Plain-English answers to the questions that come up most often on these cases.
Own Occupation vs. Any Occupation
The policy definition of disability determines whether you qualify. “Own occupation” means you cannot do your specific job. “Any occupation” — the tougher standard — means you cannot do any job at all. Most group plans shift from own-occ to any-occ at the 24-month mark.
Read moreThe Elimination Period
Before benefits begin, you must satisfy a waiting period — typically 90 or 180 days. During that window you receive nothing. Knowing your elimination period is essential for planning your short-term coverage bridge and documenting continuous disability.
Read moreERISA Pre-emption
ERISA pre-empts most state law claims against employer-sponsored plans. You cannot sue for bad faith, punitive damages, or emotional distress under federal law. Your only remedy is typically the benefit itself plus attorney fees — under 29 U.S.C. §1132(a)(1)(B).
Read morePre-existing Condition Exclusions
Group policies often exclude disabilities related to conditions diagnosed or treated in the 3-to-12 months before your coverage began. Insurers use this clause aggressively. The look-back window and the conditions it captures vary by plan document — not by what you remember telling HR.
Read moreMental and Nervous Limitations
Nearly every group LTD policy caps benefits for mental health, anxiety, depression, and PTSD at 24 months. Even when a psychiatric condition is secondary to a physical diagnosis, insurers often attempt to reclassify the claim and apply the 24-month limit.
Read moreThe LTD-SSDI Offset
Most group LTD policies reduce your benefit dollar-for-dollar by any Social Security disability income you receive. This “offset” keeps the insurer’s exposure low and is one reason insurers often push claimants to file for SSDI — the government then absorbs part of the cost.
Read moreHow we handle these cases
Obtain the full plan document and Summary Plan Description
not just the certificate of coverage.
Step 2
Identify whether ERISA governs and map the procedural consequences from day one.
Step 3
Flag every exclusion, offset, and definition that could affect your claim.
Step 4
Review the elimination period timeline against your medical records for gaps.
Step 5
Advise on the interaction between your LTD policy and any SSDI claim you are pursuing.
Real cases. Real results.
Three recent Long-Term Disability outcomes — case context and result. No client identifying information.
A client with a progressive autoimmune condition was initially denied because the insurer misapplied the own-occupation definition. After we obtained the full plan document and presented a proper vocational analysis, the claim was approved at the administrative level.
An insurance company cited a pre-existing condition clause to deny a marketing executive’s claim following a cardiac event. We demonstrated that the diagnosis post-dated the look-back window under the plan’s own terms. The insurer reversed course and paid benefits in full.
When a claimant’s major depressive disorder was secondary to a documented neurological condition, the insurer applied the 24-month mental-nervous cap. We built the medical record around the primary neurological diagnosis and defeated the limitation clause.
Prior results do not guarantee a similar outcome. Each case is evaluated on its own facts. The case outcomes shown are representative examples; details have been altered or generalized to protect client confidentiality.
Related questions
Quick answers from our FAQ library.
Other ways we help
Same firm, same approach — different practice areas under one roof.
Workers’ Compensation
Injured at work. Lost wages. Denied benefits.
Learn more →Social Security Disability
Can’t work due to a disability. SSDI & SSI claims, denials, appeals.
Learn more →Personal Injury
Car accident. Construction site. Scaffold Law.
Learn more →Workers’ Rights
Retaliation, wage theft, harassment. Plaintiff-side only.
Learn more →Long-Term Disability lawyers near you
Seven New York offices serving working clients across the state.
The attorneys who work your case
Not a call centre. The lawyer who signs you is the lawyer who shows up.
Brian M. Mittman, Esq.
Managing Partner · Markhoff & Mittman, P.C.
Call 866-205-2415 Schedule with Brian- Admitted in New York
- 30+ years in practice
- Attends Board hearings personally
Brian has personally handled New York workers' compensation, SSDI, and personal-injury cases for over three decades. Your case is never handed off to a paralegal.
- Admitted in New York and New Jersey
- Pace University School of Law, J.D.
- Litigates before the Workers' Compensation Board
Randy has litigated every type of claim before the Workers' Compensation Board on behalf of hundreds of claimants.
- Admitted in New York, 2008
- New York Law School, J.D. 2007
- With The Disability Guys since 2013
Benai has spent more than a decade fighting for injured workers before the Workers' Compensation Board and the New York State Employees' Retirement Board.
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