Fighting Wrongful Denial Or Termination Of Insurance Benefits

When your insurer denies or terminates your disability benefits, it can leave you feeling angry at someone who you thought would help you in your time of need. You would be right to feel this way, and seeking to sue your insurer would become a natural course of action.

If your case falls under the laws of the Employee Retirement Income Security Act, there are steps you need to take before being eligible to sue.

Here at ERISA Law Center in Fresno, California, our long-term disability lawyer can help you through the whole process. With over 35 years of experience in these cases, our attorneys can help you through the appeals process that ERISA law requires before you are able to sue.

Should you have to file a disability insurance lawsuit, our long-term disability lawyers bring extensive trial backgrounds to the courtroom to prosecute your case. Fortunately, disability insurance claims can often be resolved out of court once the insurance company sees that an effective case has been prepared on behalf of our client. Both sides understand that litigation is time-consuming and expensive. This can result in negotiation of a settlement or buyout. In all cases, our client retains the right to approve a final settlement.

Defend Your Future With A Strong Litigator

Some insurers might deny or terminate your benefits in the hopes that you do not pursue legal action, so they can avoid paying you. Other insurers may expect a lawsuit, and fight aggressively to keep you from the benefits you deserve.

In either case, having an experienced litigation attorney will help you protect the benefits that you deserve. When the security of your future is on the line, you cannot leave anything to chance. If an insurance company wrongly denied or terminated the benefits of you or a loved one, get the help you need.

Prelitigation Internal Appeal

Before filing suit, you must pursue a timely administrative appeal. The administrative appeal is required by ERISA regulations. If you do not submit an administrative appeal, the denial or termination of your benefits cannot be challenged in court. Because many administrative employee benefit appeals are denied, it is likely that your appeal will be denied as well. However, this does not mean that you do not have a good case.

Disability insurance companies are required under ERISA regulations to have an administrative 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.

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 do not already have your records from the insurance company, we get them.
  • If we do not 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 and 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, who are used to terminate or deny your benefits. Sometimes we have files, prior opinions about or other useful information on those doctors, which we can include 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 and your doctor – especially when you have caretakers 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 from the beginning, we start working on our appeal letter right away. However, the letter is not completed 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.

Final Points

  • 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 that 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.

You Pay Nothing Unless We Get You Benefits Or A Settlement

Let ERISA Law Center help you litigate your disability claim. Our ERISA attorneys are experienced and skilled when it comes to ERISA litigation. Contact us today. Call all our Fresno office at 866-360-0983.