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We file a complaint against the plan and/or the insurance company. The complaint seeks a declaratory judgment to require the Insurer or plan to pay or reinstate benefits, pay back benefits (with interest), pay attorney fees incurred prosecuting the suit and perhaps other remedies. Under ERISA law you are not entitled to recover any other amounts. You may not recover compensation for pain and suffering or punitive damages – you can only receive what the plan or insurance company should have paid you in the first place. You may not recover the value of future benefits, only the right to receive future month-by-month benefits month-by-month if you continue to demonstrate that you are entitled to them. (This is one of the major reasons why insurance companies deny claims and then deny appeals. If the insurance company loses in court, it only has to pay the benefits it otherwise would owe, plus, perhaps, attorney fees and interest.)


Once the complaint has been served, the plan or insurance company defends the lawsuit and the plan’s or insurance company’s attorney will file an answer to the complaint, admitting certain facts, denying most other facts.


Early in your suit, the “Administrative Record” is prepared. Usually, litigation of an ERISA benefits suit is limited to the Administrative Record: the evidence and materials obtained by the plan or insurance company before suit was filed. Often, the only evidence that is allowed to be presented in court is the administrative record of your claim, plus evidence relevant to the insurance company’s conflict of interest. This may include the plan provisions, your claim for benefits, all correspondence regarding your claim for benefits, internal insurance company reviews, records, reports, analyses and other information submitted during your administrative claim regarding “other benefits” such as Social Security or workers’ compensation, you applied for or received, the medical records the insurance company obtained or you submitted and employment records which the insurance company obtained or you submitted. Medical and other records after the denial of your appeal are generally inadmissible. New evidence is often inadmissible, except evidence that shows the insurance company’s conflict of interest.


About 90 days after the complaint is filed, the court will hold a scheduling conference. At that time deadlines and dates for various matters, including motions and trial, will be set. You need not attend this conference.


A critical issue in ERISA benefit litigation is the standard of review. Sometimes the standard of review is “de novo.” If so, the judge (there are no juries in ERISA suits) weighs the evidence without regard for or deference to the insurance company’s or plan’s decision. However, if the plan (or insurance policy) grants plan fiduciaries discretion to determine eligibility for benefits or to construe plan provisions, the judge uses the “abuse of discretion” (sometimes called “arbitrary and capricious”) standard of review. This means that the judge will defer to any reasonable opinion of the insurance company or plan. When the judge applies abuse of discretion standard of review, the insurance company can win the lawsuit even if you are disabled.


Discovery (depositions, interrogatories, -- questions to be answered under oath--), requests for production of documents, in ERISA cases is generally limited, if permitted at all, to facts and circumstances regarding the plan fiduciary/insurance company’s conflict of interest. Thus, such discovery will generally not involve you, your disability, or your medical condition. Instead, it will involve the insurance company, any the doctors who evaluated you or your records, and facts such as how often the doctors work for the insurance company, how much they are paid and how frequently they conclude that claimants are not disabled.


There commonly are one or more mediations or settlement conferences in a lawsuit. Judges encourage lawsuits to settle. Many cases settle. If we file suit for you, we will evaluate your case and prepare you to decide whether it is best for you to settle your case or fight it. The judge will require us to participate in settlement negotiations. But you – and only you – decide whether or not to settle your case.


If the case does not settle, each side usually files a motion and asks the court to grant judgment in its favor.


If the case is not otherwise decided or settled, the matter proceeds to trial. The judge decides the case – there is no jury. Usually the evidence presented is the administrative record plus, where appropriate, evidence regarding the nature and extent of the plan/insurance company’s conflict of interest. If you win the trial, the judge will issue an order that your benefits be paid retroactively with interest and that your benefits be reinstated prospectively. You only get a lump sum payout of past benefits; you do not get a lump sum payout of future benefits. If you prevail at trial, a motion to request an award of attorney fees can be filed with the court.


Many cases are not finally resolved in the trial court. Frequently, the judgment is appealed to a federal circuit court of appeals. Internal appeals take time and work; lawsuits take time and work; if your lawsuit is unsuccessful and you lose, appeals to a circuit court or appeals takes time and more work. At ERISA Law Center, we are willing and able – and experienced – to fight your case as long as it takes.

Call an ERISA Lawyer at (844) 710-2993

Let ERISA Law Center help you in your lawsuit for your disability claim. Our team is seasoned and skilled when it comes to ERISA lawsuits and appeals. Contact us today.