ERISA Experience You Can Rely On.

4 steps to appeal an ERISA claim denial or termination

On Behalf of | Oct 31, 2019 | Erisa

ERISA stands for the Employee Retirement Income Security Act of 1974.  The simplest way to understand ERISA is that it establishes minimum standards for most employer-provided retirement (pension plans), health, and other welfare benefit plans, including life insurance and disability insurance plans.

If you believe you qualify for ERISA disability benefits but have recently received a denial or termination of your claim, you may feel defeated.  Now what?  There are steps you can take to appeal the denial or termination of your benefits.

  1. You should consider retaining the services of an experienced ERISA attorney.  Under ERISA, the appeal process is very important because it is normally the only opportunity you have to prove your disability – if and when your appeal is denied, no new evidence can be considered by the court and therefore, submitting a thorough appeal, addressing all the insurance company’s assertions and providing your own evidence usually is of utmost importance.
  2. Read the insurance company’s letter to understand the reasons for denial or termination of disability benefits.  If you have an attorney, your attorney will do this and address those reasons in the appeal.
  3. Gather your documents proving right to benefits, including all of your medical records.
  4. If you choose to submit the appeal yourself, it must be submitted within the time outlined in the denial letter, which is normally 180 days, though that number can be different depending on the situation.  Make sure your appeal is detailed, thorough and explains why your medical condition(s) make it impossible for you to work.

Appealing a claim denial or termination is a time-consuming and mentally draining process. The insurance company may draw out the process in a variety of ways, including taking the additional time it is entitled to under ERISA, sending you to examinations or functional capacity testing, or contacting your physician(s) for their opinions. Awareness of the time involved ahead of time may alleviate some, but obviously not all, of your stress.

The insurance company will often deny your appeal because there is no incentive under ERISA for it to grant the appeal. If your appeal is denied, the only remaining recourse is to file suit in Federal Court.

What can a lawyer do for you?

Although it is not absolutely necessary, prior to filing suit, you should seek the advice of an attorney experienced in ERISA, if you did not retain one during the appeal process.  Once you have engaged the services of an attorney, the attorney will initiate the litigation process in an effort to obtain your disability benefits.

If your attorney is experienced in ERISA, there are basic steps that will be taken prior to initiating the litigation process:

  • Obtain the insurance company’s file of your disability claim;
  • Analyze what the insurance company did versus what was submitted in the appeal process;
  • Draft a complaint that details the facts and issues presented;
  • Present the draft complaint to you for approval;
  • File the complaint in the appropriate Federal District Court to begin the litigation process.

Submitting a thorough appeal is necessary for the success of obtaining your ERISA disability benefits.  For this reason, while you are not legally required to hire an attorney, utilizing the knowledge an experienced ERISA attorney may make a difference in winning your claim.