The Employment Retirement Security Act of 1974 (ERISA) was originally introduced to protect employee pensions. But Congress later amended the law to include all worker benefits, including long-term disability plans provided by private employers.
If you suffer a debilitating injury or illness that leaves you unable to work and support your family, it’s crucial to consult your employer’s plan to see whether your condition is covered. But even if it’s on the list, there’s no guarantee that the insurance company administering the plan will sign off. Claims are denied for the tiniest of technicalities.
The reality of filing an appeal
While ERISA laws protect workers, they were crafted, in part, by special interest groups, such as insurers. That means most people who try to navigate the process alone typically find the deck stacked against them. Here are some disturbing things to know about ERISA appeals:
Insurers get the benefit of the doubt
To win an appeal, you must prove that the denial was wrong and that the insurance company abused its discretion in denying benefits. This is a much higher standard than is required in most legal proceedings.
You can’t introduce new evidence in the lawsuit phase
While you have the right to sue if your claim and appeal are denied, the judge will only consider the arguments and documents submitted through the appeals process. That’s why it’s crucial to include all doctor’s opinions, medical files or other relevant evidence as early in the process as possible.
Insurers rarely face any consequences
Insurance companies are aggressive in denying claims to preserve their bottom lines. Even if they make mistakes and an appeal or lawsuit goes in your favor, they are not penalized for wrongfully denying a claim. Their worst-case scenario is paying you the benefits you were entitled to in the first place.
Beware of the deadlines
While you may have up to 180 days to file an ERISA appeal, the denial letter from the insurer may designate a shorter period. This is another major difference compared to other appeals processes. If you miss the deadline, you typically can’t file a lawsuit to recover benefits.
These facts are not meant to scare you but emphasize the importance of doing things the right way when filing a long-term disability claim and especially when appealing a denial.
ERISA law is complicated, which is why many people benefit from guidance from attorneys specializing in this area. Talking to an experienced ERISA lawyer before filing a claim is advisable, so you receive timely benefits offered under your employer’s plan.