California ERISA Lawyer

Trusted Advocates for California Policyholders

At Sandstone Law Group, we stand beside Californians who have been wrongfully denied the long-term disability (LTD) benefits they are owed under ERISA-governed plans. If your insurer has delayed, denied, or underpaid your disability claim, you are not alone, and you do not have to accept it.

We represent professionals, executives, and employees from all industries who have paid into their employer’s disability insurance plans with the understanding that help would be there when needed. Now that you are facing a serious medical condition, injury, or impairment, your insurer is turning its back.

We are here to fight back. Contact Sandstone Law Group today at (602) 615-0050 for a consultation.

What Is ERISA?

The Employee Retirement Income Security Act (ERISA) is a federal law enacted in 1974 to regulate employer-sponsored benefit plans and protect workers' rights to those benefits. While it was drafted to provide pension protections, Congress tacked on a broad range of employee benefits at the last minute, including:

• Long-term and short-term disability insurance
• Health, dental, and vision coverage
• Life and accidental death insurance
• Retirement and pension plans

This means that ERISA was not drafted with long-term disability benefits in mind, which has led to serious deficiencies in the law. If your employer offers benefits through a private-sector plan, whether fully or partially funded by the company or through payroll deductions, there is a strong chance ERISA governs your coverage. Public employees are exempt, and religious organizations are often exempt, as well. Individual policies are usually governed by state law and not ERISA.

How ERISA Affects Your Disability Claim

At its core, ERISA was designed to hold employers accountable by requiring transparency and fair treatment in the administration of employee benefits. However, over time, ERISA has evolved into a highly technical and insurer-friendly system—one that makes it incredibly difficult for individuals to challenge wrongful denials or delays without legal help.

Under ERISA:

You cannot seek punitive damages, even if the denial was malicious or outrageous.

You have no right to a jury trial.

The court typically cannot consider any new evidence beyond what was submitted during the insurer’s internal review process or otherwise a part of the “administrative record”.

The only remedy is often being put back on claim with the insurer or, worse, simply a remand back to the insurance company for further claims handling.

Future benefits do not vest, so a court cannot award them. 

In short, ERISA strips claimants of many legal protections that would otherwise be available in a non-ERISA insurance dispute. Insurance companies know this. And they take advantage of it. Under ERISA, the risks of denying valid claims are low, while the rewards of delay or refusal are high.

In California, you do have additional protections, such as the ban of discretionary clauses, entitling you to de novo review in court. California Insurance Code § 10110.6 prohibits discretionary clauses in group disability policies issued or delivered in California. This means insurers cannot give themselves discretionary authority to interpret the terms of the policy or decide eligibility for benefits. As a result, federal courts apply de novo review, not the deferential “abuse of discretion” standard.

But even with de novo review, ERISA limits your ability to introduce new evidence in court to certain circumstances, making the administrative record the main battleground for your case. The administrative record is basically “the official insurance claim file” — everything the insurance company had in front of it when it made its decision on your claim. New evidence is typically only admissible under narrow exceptions, such as: if the record is incomplete; if procedural irregularities occurred; or if the insurer acted in bad faith or unreasonably limited the record. This makes the administrative record of central importance to your case.

That is why it is critical to get legal counsel early. If you are still in the appeals process, we can help build a comprehensive and compelling record that puts pressure on your insurer. If you have already received a final denial, we are prepared to review your case for federal court.

Common ERISA Denial Tactics

Insurance companies often present themselves as impartial decision-makers, but the truth is far more disturbing. These companies often operate under a “structural conflict of interest”, which leads to them minimizing payouts to maximize profits. ERISA, while originally intended to protect employees, has become a tool insurers manipulate to serve their own interests in many contexts of how these cases are litigated. Understanding the tactics they use can help you anticipate and fight back against unfair denials.

Here are some of the most common and insidious strategies insurers deploy against legitimate claims:

Manipulating Policy Language to Serve Their Agenda

Insurers often cherry-pick or stretch interpretations of your policy to justify a denial. This may include:

• Labeling legitimate conditions as “self-reported symptoms” to dismiss or improperly demand objective medical evidence, even if the policy does not require such evidence (e.g., migraines or fibromyalgia).
• Blaming your disability on a mental health condition to exploit mental illness limitations, even when your primary issue is physical and well-documented.
• Twisting pre-existing condition clauses far beyond their intent, like denying claims based on loosely related or completely distinct past health events.
• Using the “test change,” or change in definition of disability, to argue that you can work in other occupations. 

What seems like a routine denial is often a deliberate misreading of the plan language designed to avoid liability.

When it comes to considering other work, in California, even ERISA-governed disability insurance claims benefit from added protections when the policy was issued or delivered in the state. One of the most important safeguards involves how insurers evaluate whether a claimant can perform “any occupation.” Under California insurance regulations, insurers must consider not just your training, education, and experience — but also your age, mental capacity, and physical limitations. This means they cannot deny benefits simply because you could perform a generic job, especially if age-related factors or cognitive impairments affect your ability to work. These requirements ensure that “any occupation” truly reflects your realistic employability, not hypothetical job matches that ignore your actual condition.

Relying on Paid Medical Reviewers and Biased Third Parties to Undermine Your Claim

Insurance companies don't work alone when building the case to deny your ERISA disability claim. They frequently hire external vendors and consulting firms that specialize in minimizing payouts. These third-party companies perform so-called “independent” medical reviews, vocational assessments, medical examinations, or functional capacity evaluations—but the truth is, they are often anything but independent.

Some of the common tactics used by these third parties include:

• Cherry-picking medical records or ignoring key evidence in your favor (“garbage in, garbage out”).
• Using non-specialist reviewers who lack appropriate expertise to cast doubt on complex conditions.
• Producing vocational reports that suggest you can perform “sedentary” or “alternative” work—even if your doctors say otherwise.
• Issuing rubber-stamped opinions that align with the insurer’s goals, especially from vendors or contract companies used repeatedly due to their claim-denial track record.
• Conducting arbitrary surveillance around medical appointments, for example, and wrongfully representing that surveillance as an ability to work. 
• Misconstruing social media posts to engineer purported inconsistencies in your reported restrictions and limitations. 
• Calling or sending biased forms directly to your treating providers without your knowledge and faulting you if your doctors do not call back or return the forms fast enough.  

Sometimes, they examine you in person by conducting an “independent” medical examination. These so-called “independent” doctors often are the wrong specialty for your conditions, fail to consider you as a “whole person,” review incomplete medical records, and fail to spend sufficient time to really understand the nature of your disability. 

These vendors are not accountable to you—they are hired and paid by the insurer. Their primary purpose is not to provide objective truth, but to build a narrative that justifies denial.

They will argue that your symptoms are exaggerated, that treatment is unnecessary, or that your condition does not prevent you from working, even if your treating specialists provide extensive, consistent documentation to the contrary. It is about manufacturing doubt and, frankly, trying to make you feel like a liar. If the insurance company can bully you into walking away from your claim, that only means more money in their coffers. 

Deploying Selective Surveillance to Create a False Narrative

Surveillance is a favored weapon for disability insurers. They will hire private investigators to:

• Record brief moments of activity (e.g., walking to the mailbox or attending a short event).
• Ignore the dozens of days when you are bedridden or in visible distress.
• Twist normal daily behavior into “proof” that you are not disabled.

This tactic often misrepresents reality, especially when short bursts of movement are used to invalidate chronic, ongoing impairments. Insurers will often order surveillance around medical examinations that they are sending you to attend, because they know that you will be leaving the house. And claimants often take those opportunities to run errands because of the effort it takes to attend a medical appointment. 

Burying or Excluding Favorable Evidence

Insurance companies will often omit, minimize, or entirely ignore evidence that supports your claim. This may include:

• Positive assessments from your treating doctors.
• Vocational evaluations confirming you cannot work.
• Test results or functional capacity evaluations validating your symptoms.

They may also issue denials with vague or cryptic explanations, forcing you to request the full claim file just to uncover what they did not tell you.

Violating Basic ERISA Safeguards

ERISA technically requires insurers to have your claim reviewed by a physician of comparable training and specialty to your treating provider. But this is often overlooked or outright violated.

For example, if your disability is neurologic in nature, ERISA rules require review by a neurologist, not a generalist, not a psychiatrist, and certainly not someone unfamiliar with your condition.

Why Choose Sandstone Law Group?

At Sandstone Law Group, we fight to restore dignity, financial stability, and peace of mind to people who have been wrongfully denied the benefits they worked for.

We understand that no one wants to be in the position of needing legal help just to access disability benefits. Most of our clients would give anything to be healthy again, to work again, to be free of pain. But when the insurance company refuses to uphold its promises, we step in with conviction, empathy, and relentless resolve.

·         We Listen First, and Then We Fight: When you come to us, you will find attorneys who listen. Really listen. You will not be rushed through a consultation or treated like a case number. Our team is known for creating a space where clients feel heard, validated, and understood. From that foundation, we build powerful, personalized legal strategies rooted in your experience and medical reality.

·         We Know the Playbook: We’ve taken on nearly every major disability insurance company—and the web of third-party vendors they rely on to justify denials. From biased “independent” medical reviewers to outsourced vocational experts and surveillance firms, we’ve seen how insurers build their case through a network of paid evaluators. We know their tactics, and we know how to dismantle them. Our attorneys have handled every stage of the ERISA process, including:

Internal appeals and administrative reviews.

Managing IMEs, peer reviews, and vocational evaluations.

Navigating complex medical and psychological disability evidence.

Litigating denied claims in federal court.

Identifying procedural violations and leveraging them to strengthen your case.

·         We Are Litigation-Ready: While many firms prefer to settle quietly, we prepare every case with the assumption it may go to court. That reputation alone puts pressure on insurance companies to treat our clients more fairly. And when going to a lawsuit is necessary, we have the experience to back it up. Whether your case resolves through negotiation or litigation, we are ready to see it through to the end.

·         We Treat Clients Like Family: Our team brings a rare combination of fierce legal acumen and deep compassion. We treat every client’s fight like it is our own because, in many ways, it is. We have walked alongside families who have been ignored, dismissed, and dehumanized by the very companies they trusted to protect them. Your fight is personal to us, and you can count on us to care about the outcome we secure for you. 

If your disability claim has been denied under an ERISA plan, you are facing a system that was not designed with your best interests in mind. But you do not have to face it alone. Choose a firm that listens, understands, and takes action. Choose Sandstone Law Group.

We Will Take Your Case to Court

When insurance companies deny valid long-term disability claims, they count on people giving up. They rely on the complexity of ERISA and the fear of federal court to stop you from fighting back. At Sandstone Law Group, we do not back down. If litigation is necessary, we are ready and experienced.

If your claim is governed by ERISA, your case will be heard in federal court, and your path to justice will look very different from a typical insurance dispute. 

ERISA in California

Federal courts across the country interpret ERISA differently. Here in California, we benefit from some of the strongest consumer protections in the nation:

• California law bans discretionary clauses in disability insurance policies.
• As a result, many ERISA cases here receive de novo review, which levels the field and gives claimants a fairer shot.
• Courts in the Ninth Circuit (which includes California) are generally more claimant-friendly in interpreting ERISA than courts in other jurisdictions.

We use every tool available, from state law protections to circuit court precedents, to tip the scales back in your favor.

While we are fierce advocates in and out of court, it is important to understand that ERISA litigation is unlike traditional lawsuits:

• No punitive damages: Even in the face of bad faith, ERISA does not allow compensation for emotional distress or pain and suffering.
• No jury trials: Cases are decided by a judge, based on written submissions, not courtroom testimony.
• No shortcuts: Before suing, you must first exhaust all internal appeals through the insurance company.

This means your legal team must be meticulous, strategic, and fully prepared—because your entire case may hinge on what was done before a lawsuit is ever filed.

We do not treat litigation as a last resort; we prepare for it from the moment we take your case. Our team has the knowledge, courtroom experience, and tenacity to challenge insurers at every level.

You Paid for Protection. We are Here to Make Sure You Get It.

You did everything right. You worked hard, paid into your benefits, and counted on your long-term disability insurance to be there when life took an unexpected turn. But now, instead of support, you are facing silence, delays, or outright denial. That is not just wrong, it is unacceptable.

At Sandstone Law Group, we believe that insurance companies should be held accountable for the promises they make. We do not take shortcuts. We do not settle for generic advice or passive representation. Our team is built to fight, and we fight with precision, passion, and a deep respect for the human stories behind every claim.