ERISA Appeals and Lawsuits
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In order for you to get your ERISA disability insurance claim approved you must follow certain required steps. This includes submitting a timely appeal and, depending on the insurance company's policy, possibly filing a second appeal. If and when your appeals are denied a lawsuit can be filed. All of these steps have time limitations that must be met, or you will lose your right to continue to the next step of your claim.
With extensive experience in disability and life insurance claims governed by the Employee Retirement Income Security Act of 1974 (ERISA), ERISA Law Center can represent you in your appeal or lawsuit for benefits.
Pre-Litigation Internal Appeal
Before filing suit you must pursue an internal appeal. The internal appeal is required by law; if you do not submit an internal appeal, the denial or termination of your benefits cannot be challenged in a lawsuit.
Most internal employee benefit appeals are denied, so it is likely that your appeal will be denied as well. This does not mean that you do not have a good case.
Disability insurance companies are required by law to have an appeal process, so they do. However, there is very little “downside” for an insurance company to deny an appeal because many people do not find a lawyer and most people do not sue. Even when suits are filed, the courts often support the insurance company's decision, so the disability claimant is faced with a significant challenge.
We have successfully sued Aetna, American United, Anthem, Assurance, Blue Cross, Cigna, First Reliance, Guardian, Hartford, LINA, Lincoln Financial, Matrix, MetLife, Mutual of Omaha, Provident Life & Accident, Prudential, Reliance Standard, Reliastar, Sun Life, The Standard, United of Omaha, Unum, and plans administered by Sedgwick.in federal district courts around the country and reached settlements or won hundreds of cases on behalf of our disabled clients.
This is generally how we handle an administrative appeal to an insurance company or third party claims administrator after benefits have been denied or terminated:
- If we don’t already have your records from the insurance company, we get them.
If we don’t already have the insurance policy, the certificate of insurance, and/or the summary plan description from your employer, we get them.
We identify all your current treating physicians and any other treating physicians who are not listed in the insurance company’s records. We get authorizations from you. We use those authorizations to get current medical records. It is important to submit new medical evidence with the appeal and we try to be as comprehensive as possible in submitting new medical evidence.
If your doctor’s records are unclear or if there is any uncertainty, we may ask your doctor to submit a detailed report regarding your status. If your doctor’s opinions are contradicted by the insurance company’s opinion, we may ask your doctor to make a comment on the insurance company’s doctor’s opinions. A lot of doctors are not willing to do “legal medical” evaluations. They often do not like writing letters to insurance companies; they often do not like talking to lawyers. We may ask you to talk to your doctors; we may write a letter to your doctor; we may call the doctor’s office.
We investigate the insurance company’s doctors – the doctors they used to terminate or deny your benefits. Sometimes we have files on the doctors. Sometimes we can find prior opinions or other useful information from public records. If we can find negative or other useful information on the doctors which the insurance company relied upon, we include that in the appeal.
Sometimes, the defense doctors do not properly understand the disease from which you are suffering. We often include medical literature regarding your disease and/or symptoms.
We believe that it is important that you submit a declaration supporting your claim. Based on a review of the records that we have, we will draft a declaration for your review and approval. We will then send the declaration to you and ask you to comment on it and make corrections, changes, and/or additions. Sometimes we get declarations from persons other than you and your doctor – especially when you have care takers or significant others who can describe the nature and extent of your disability. Sometimes we submit a video showing how you live so that the insurance company can fully appreciate how disabled you are.
Since we have a lot of information almost from the beginning, we start working on our appeal letter almost from the beginning – but we do not finish it until we have all the information we need.
If you have Social Security Disability or workers’ compensation benefits we get the records from those claims.
Our appeals generally consist of a lengthy appeal letter often of 50 to 100 pages, together with your declaration, perhaps your doctor’s letter, if necessary, perhaps other declarations (if necessary), medical literature about your conditions and symptoms, new medical records, whatever information we obtain about the insurance company’s doctors, information we have (if any) about the insurance company’s unfair practices, etc. The insurance company has 45 days to decide most appeals. However, usually the insurance company takes more time and requests more time. Therefore, the appeals are usually not decided until approximately 75 days after they are submitted. (For claims that arose before January 1, 2002 the insurance company has 60 days plus 60 days, not 45 plus 30 days). When the insurance company orders additional medical reviews or an independent medical examination that may further delay a decision on the appeal – by several additional weeks or even months.
It is also important to submit a comprehensive appeal because if you have to sue, once you go to court, most of the time the only evidence which a court will consider on the merits of your claim is the evidence in the administrative record. So, if we do not put it in now, it is likely the judge will never see it.
If your appeal is granted, then you will be placed back on claim retroactively and paid back benefits. If the appeal is denied, we will usually file suit seeking benefits through the litigation process.
At ERISA Law Center we can file a lawsuit against a disability insurance company for the wrongful denial or termination of benefits.
If your internal appeal has been denied, you may file a lawsuit. Here’s what usually happens: