If your claim for long-term disability benefits under an ERISA-governed employee benefit plan was denied, you have the right to appeal the denial. However, federal ERISA rules are strict and tend to favor the insurance company, thereby making it even harder on a disabled claimant to pursue benefits.
Here are six critical points you must know when going up against a rather unfair system to pursue wrongly denied disability claims governed by ERISA statutes.
- Federal ERISA preempts state law. This means that state law enforcement procedures and remedies like bad faith and insurance code violations are not available to you. Also, you cannot pursue a lawsuit without first exhausting the disability plan’s administrative remedies and appealing the denial.
- The administrative appeal is critical because it is your final chance to state your case for disability, and is your last opportunity to submit evidence into the administrative record to support your claim. However, do remember that the appeal is not your last step. It is a step towards proving your claim and obtaining benefits, or it is a step toward potential litigation if the appeal is denied. The administrative appeal remains as the most important part of your claim, and will be the basis of legal arguments later in your case.
- Once the insurance company makes the final denial of an administrative appeal, no further evidence may be submitted to the claim.
- If your denied appeal goes to trial, it will be in federal court. The court is basically reviewing the stacks of documentation as submitted in the appeal. There will be no live testimony and no trial by jury – human theater is taken out of the picture. The stacks of medical records, vocational records, job history and other records must somehow illustrate to the judge that an actual individual is truly disabled and has a story to tell that has changed that person’s life.
- If the appeal goes to court, the insurance company is given the benefit of the doubt in many cases. The court views a denied claim under ERISA rules, which state that the insurance company has discretion to deny the claim as long as they have acted reasonably.
- The insurance company knows that if they wrongly denied your claim, all that can happen is the court will order them to pay the claim they originally denied, and perhaps pay the claimant’s attorneys fee. There will be no lawsuits or big cash settlements for punitive damages, bad faith or emotional pain and distress because ERISA prevents that.
So How Can You Overcome the ERISA Process?
It boils down to proof. During the 180 days in which you are allowed to appeal your denied ERISA claim, you must prove that you should be awarded disability benefits.
It is very important to work with an attorney as soon as you have been denied benefits. An experienced disability insurance attorney knows exactly what to include in the appeal. Specific medical and vocational examinations, testing, reports, witness statements, doctors notes and many other forms of proof of disability can create the objective evidence that truly bolsters your claim file in support of your disability. And with ERISA claims, your rights are often determined by what happens early in the claim.
Our ERISA lawyers work with the disabled every day to help them obtain their wrongly denied benefits. We are intimately familiar with ERISA law. We have extensive experience dealing with medical and vocational records and are able to quickly analyze and understand those records which are critical to our client’s case.
For a free legal consultation, call 800-562-9830
An experienced ERISA Attorney can be immensely valuable to you.
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