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Assessing the Burden of Proof for Disability Claims in Non-ERISA Plans in San Jose

This legal question related to social security & disability law... in San JoseCalifornia has been answered.


I was a police officer 10 years. I had one night after work came home and was eating dinner and went into a major grandma seizure where I fell, broke my back and was hospitalized. This then happened again to me 1 month later, again while at home.  I was out of luck as this was not a workers compensation issue given the proof to show it was work related was not a chance per everyone and legal aid I sought. Nonetheless, I made a full recovery in 2015 (after being off work nearly 8 months on light duty).  Upon my return to work, I thought I was fine. Others noticed I was not. I developed major neurological issues related to memory, ability to write, time management, being able to focus and more. It got to the point where I was basically forced to retiree as I was not cutting the standards. And this is from a cop that's been doing this since he was 13 as a police explorer and who has won many awards for his hard work, youngest to ever promote in the department etc.

Thankfully, I had paid into a "NON PROFIT DISABILITY COMPANY WHO IS NON ERISA" that fought me from day 1 and did not want to pay me even tho all doctors agreed I was disabled from my "own occupation".  I was awarded for 24 month disability pay. The disability company will pay life benefits assuming your "totally disabled" from all jobs after 24 months. 

My doctors to this date have documentation and call my issue a neurological disorder have put me totally disabled for the purpose of the company accepting my claim because my doctors no i'm NOT fit to be working with my issues. Its's now been 24 months and the NON PROFIT company has wrote me a denial letter indicating it's their belief I can reasonably go back to work and by that, they rule I don't meet the total disability standard of their plan. This is based on their doctor review of my records and based on their administrator doing the review (of course in their favor). However, my doctors who have treated me indicate I am not to work and totally disabled. So who has the burden of proof?  WHY hasn't the company ordered me to take a Vocational Assessment?

I looked into paying for a vocational assessment on my own but that's $5000 I don't have. So what other proof is needed for the company to believe me.  They don't have to obey ERISA and skated that too by being non profit.  What case law supports my case in that weight from my doctors trump the "opinion" of the administrator and their company doctor who has never met me a day in their life.

WHO can prove I am disabled to the plan and how else do I do this. If my own doctors cant persuade the company enough what else do I do. Do I just accept their denial and assume there is no way to get them to overturn this.  I don't have money for a legal attorney any longer. This service was being provided to me and the reason I got benefits to begin with. But has the company drags their feet longer, my attorney fees got to the point I can't afford the attorney any longer and I am maxed out financially, and not working cause I cant. Furthermore, social security is not an option for me as police officers don't pay into social security.  I had 1 year of state disability but that's exhausted and I am at a place in time without help or anywhere to turn to.  I am stuck and this company should be paying. But again who has the burden of proof to establish if I am disabled. I have supplied my proof that shows I am.  They can do this too me because they are non erisa and have less restrictive law.

Thank you for your time in reading this long question and any help is much appreciated. 

Quick reply - burden of proof, police officer and hospitalization:

The question of who has the burden of proof can often decide the outcome of litigation. What does "Burden of proof" mean in law? In a legal dispute, one party is initially presumed to be correct and gets the benefit of the doubt, while the other side bears the burden of proof. A non-ERISA plan with over 100 participants does not require an annual audit. Unlike most companies, non-profit organizations are exempt from Employee Retirement Income Security Act (ERISA). ERISA was created to protect employees' rights to receive benefits, including disability claims.

How to find an excellent social security & disability lawyer for your case? Browse our list of social security and disability law firms near you and resolve your "disability" and "burden of proof" issue! Compare attorney fees, experience, reputation among clients, and services offered. 

Commonly posted questions...

Assistance with Disability Benefits in Los Angeles
5 years 1 month ago, social security & disability law..., Los Angeles

Legal Solution

The response provided below is specific to social security & disability law... in the jurisdiction of San Jose. If the response is inadequate, please submit a detailed inquiry.

Assessing the Burden of Proof for Disability Claims in Non-ERISA Plans in San Jose


When confronting a denial of disability benefits, particularly from a non-ERISA plan, the burden of proof usually falls on the claimant. However, a discrepancy between the diagnosis and prognosis of treating physicians and the insurers' chosen doctors is not uncommon. A thorough understanding of the laws and the disability plan's specific terms is crucial.

Relevant Legal Framework

Potential Solutions

  1. Reappeal the Decision: Given that your treating doctors have labeled you as "totally disabled," their opinions should hold significant weight. You might consider drafting a comprehensive appeal letter, enclosing all necessary medical documentation and any testimonies or detailed observations from your colleagues or superiors about your deteriorating job performance.
  2. Independent Medical Examination: If affordable, obtain an independent medical examination to corroborate your disability claim.
  3. Vocational Expert's Testimony: A vocational expert can offer insights into your employability in any occupation, not just your previous job. Given your situation, it's odd that the company hasn't required such an assessment yet.
  4. Legal Aid: Some organizations provide legal aid for those who can't afford attorney fees. While you've exhausted your personal attorney, there might be other avenues for legal assistance. You might compare lawyers in your area to find pro bono representation or someone willing to work on contingency.
  5. Public Awareness: While this is a more radical step, highlighting issues with non-profit disability companies skirting regulations can bring public scrutiny and sometimes compels companies to act more fairly.

Average Legal Costs in San Jose

Service Average Price (USD)
Consultation with a Disability Lawyer $250 - $350
Independent Medical Examination $1,200 - $2,000
Vocational Expert Consultation $1,500 - $3,000
Comprehensive Case Review & Appeal Drafting $2,000 - $5,000
Court Representation (if it comes to that) $5,000 - $20,000

Note: Prices are estimations and can vary based on the complexity of the case and the lawyer's expertise. It's also worth noting that San Jose, being part of the Bay Area, might have higher legal fees compared to other parts of the country.

Clarification and Action

It's crucial to understand every detail of your situation to provide the best advice. To better help you, would you be able to provide more specifics on the terms of your disability plan? Don't let a denial letter be the end of your journey. Fight for your rights and entitlements!

Relevant Questions for Further Analysis

  1. Have there been any other similar cases against this non-profit disability company? This can help understand their modus operandi.
  2. What exact clauses or terms in the plan are they referencing to deny your prolonged disability claim?
  3. Have you been keeping a personal log or journal of your day-to-day health challenges? This can be valuable evidence.

What are the specific terms of your disability plan regarding total disability?

Understanding the exact wording can help tailor your appeal more effectively.

Why are non-ERISA plans less stringent, and how can claimants safeguard themselves?

Non-ERISA plans, especially non-profit ones, aren't bound by the same federal regulations as ERISA plans, giving them more leeway. Claimants should always read the fine print and potentially consult with an attorney before signing up.

How often are doctors employed by insurance companies biased in their reviews?

There's a potential conflict of interest, as these doctors might face pressures to favor the insurer. This is why the testimony of an independent medical expert can be invaluable.

What are the success rates for appeals against denied disability claims?

While it varies, being thorough in your appeal, providing extensive medical evidence, and having a clear legal strategy can significantly boost your chances.

Can public opinion or media coverage influence the decisions of these non-profit disability companies?

Yes, bad publicity can often force companies to reconsider their decisions, especially if there's compelling evidence suggesting they're in the wrong. However, this strategy should be approached with caution.

Remember, while it's essential to understand your legal standing, it's equally vital to find the right lawyer who can guide you through this challenging journey.


This content is for informational purposes only and does not establish an attorney-client relationship. It's always recommended to consult with a local attorney about your specific situation.

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