ERISA Appeals

ERISA provides extremely strict deadlines and guidelines. If a claimant does not adhere to these strict guidelines and deadlines, the result can be disastrous for the claimant. Unfortunately, while insurance carriers are not free to ignore their obligations under ERISA too often claimants are unaware of their rights and violations go unchallenged.

Unlike private disability policies, when a claim for disability benefits governed by ERISA is denied, the claimant MUST appeal directly to the insurance company that originally denied the claim. If an ERISA governed disability claim is denied, the regulations that govern ERISA require insurance companies to explain to claimants the reason for the denial and what information is needed to support their claim.

What claimants are not told by their insurance company can be the most important information. Before submitting your appeal, it is essential that you understand the hidden pitfalls ahead, what type of information you should be submitting, and the time frames in which you must appeal and your carrier is required to answer.

ERISA Appeals Timeline

Most ERISA disability insurance claims allow the claimant 180 days from the date of receipt of a denial correspondence to appeal the insurance company's decision. Some policies require that the claimant complete a second level of appeal before they are permitted to file a lawsuit. While appealing to the insurance company that already denied your claim may seem like a fruitless effort, ERISA appeals should never be taken lightly. If you do not exhaust these administrative remedies, in most cases, you will be barred from filing a lawsuit in a court of law.

Insurance carrier's typically have 45 days to make a decision on your ERISA appeal. Insurance carriers are also allowed to take two thirty day extensions for good cause shown. If these deadlines are not met and your insurance company is delaying the payment of your claim, you may be able to immediately file a lawsuit. However, it is recommended that you proceed with caution and obtain clarification as to your rights and obligations before taking this step.

The administrative appeals process is an important one. After the claimant has exhausted their administrative remedies and the denial of benefits is upheld by the insurance company, the claimant is free to file a lawsuit. However, under most circumstances, the only evidence permitted to be presented in the lawsuit is the information and documentation provided during the application and appeals stage. Any evidence left out will likely never be able to be presented to the judge at trial.

Claimants should be aware that when they are preparing their ERISA appeal, they are essentially preparing their entire trial in the event that the denial of benefits is upheld by the insurance carrier.

Most individuals would not think about going against their insurance company and its lawyers in court without their own legal counsel to put together the right evidence to present to the judge. However, this is exactly what unrepresented claimants are doing when they prepare their own administrative appeals.

Your trial will not be presented to a jury, but rather to a judge. Typically in an ERISA governed disability lawsuit, the claimant is no longer proving that they are disabled, but that the insurance company acted unreasonably in denying the claim. Accordingly, providing the right information during the administrative appeals process is even more important to preserve your rights. However, under most circumstances, insurance companies are limited to the original reasons set forth in their correspondences prior to the final mandatory appeal and are not allowed to put forth new reasons for a denial of benefits if no additional appeals are provided to the claimant. Often violations of this requirement go unchallenged because claimants and even uninformed attorneys are unaware of their rights.

Relevant Evidence Must Be Included From the Start

Most disability insurance cases involve complicated medical, vocational, and legal issues. Insurance companies typically expend unlimited resources in retaining physicians, vocational experts, and lawyers to bolster their denial of benefits during the application and appeals process. Claimants often do not have the resources or are unable or unaware of how to gather the right information to challenge their insurance company's evidence. The results can be disastrous. Again, if a claimant fails to provide any relevant information prior to or with the appeal and the insurance company upholds its denial of benefits, the claimant will typically be forever barred from bringing forth the new evidence at trial.

The attorneys at Disability Insurance Law Group take ERISA appeals very seriously and always prepare each claim as if we may have to present the appeal at trial. Because of our experience in preparing these appeals and litigating these claims, we understand what information is needed to prepare an effective appeal and the complicated legal issues that must be considered. We work closely with our clients' treating physicians in order to provide the right information during the appeals process. We create our own forms for the physicians to complete, allowing our clients' doctors to thoroughly explain our clients' conditions, limitations, and disabilities. Moreover, we often request sworn statements from our clients, as well as our clients' physicians, co-workers, friends, and family members. We also typically send our clients to independent medical and vocational experts to challenge the insurance company's often manufactured "evidence" during the appeals process and if need be, in a court of law. The attorneys at Disability Insurance Law Group will not hesitate to expend the time and resources necessary to aggressively advocate on our clients behalf during the appeals process or at trial.

The Importance of Obtaining Experienced Legal Representation

Insurance companies do not explain to claimants that they must exhaust their administrative remedies and that they are essentially preparing their trial during the appeals stage because an uninformed claimant may sabotage their own claim. Insurance companies employ well trained claims representatives, experts, and attorneys to highly scrutinize these claims. Most claimants do not understand that they are going up against their insurance company's lawyers and experts from the beginning of their claims.

Insurance companies often employ deceptive tactics to trick claimants into providing insufficient proof of their claim. This may include:

  • Encouraging a claimant to immediately appeal a denial of benefits and thus, there is less of an opportunity to consult an attorney and/or obtain the necessary information to overturn a denial during the appeals stage or at trial
  • Suggesting that specific information is outstanding and a denial may be overturned simply by providing the missing information. Unaware claimants are often lulled into appealing the denial and ultimately preparing their trial with a couple of medical records
  • Tricking a claimant into attending an Independent Medical Examination during the appeals stage to bolster the denial (if no additional appeals are provided, such a request is usually inappropriate)

Oblivious of the rights they are giving up, many truly disabled individuals severely damage their claims for benefits.

It is essential that you understand your rights and obligations under your policy and the law, are aware of the typical tactics employed by insurance companies, and chose an attorney with the experience and knowledge in handling these complex claims. The Attorneys at Disability Insurance Law Group are known for our knowledge in this area and our aggressive representation of our clients at all stages of the disability insurance process.

Non-ERISA Group Disability Insurance Claims

Not all group disability insurance claims are governed by ERISA. However, because of the strict guidelines and deadlines that ERISA places on claimants, many insurance carriers assert that the claim is governed by ERISA, even if it clearly meets one of these exceptions.

If claimants are unaware that their claims are not governed by ERISA, they may be unnecessarily delaying the payment of benefits or unknowingly giving up many rights. However, if a claimant is unsure of whether their claim actually falls under ERISA, it is highly recommended that they seek advice before disregarding any ERISA deadlines.

The experienced lawyers at Disability Insurance Law Group are dedicated to using their knowledge and experience in handling these complex legal issues, to vigorously fight to protect our clients' rights. Many denials can be overturned prior to litigation, by effectively preparing an ERISA appeal. However, if an insurance company refuses to overturn its wrongful and unreasonable denial, we will aggressively fight to obtain all the benefits owed to our clients in a court of law. The insurance companies understand that we will vigorously fight to defend our clients' rights and if we prepared the appeal, we have the ammunition to do so.

Let Us Deal With Them for You

There are many potential pitfalls in the ERISA appeals process which the uninformed claimant may be ill-equipped to avoid. The attorneys of Disability Insurance Law Group have substantial experience in representing clients in Florida, the Southeast and nationwide in ERISA appeals and lawsuits.

To discuss your situation with an experienced lawyer who can help you evaluate your options and navigate this complex system, we invite you to contact our offices to schedule a free face-to-face or telephone consultation.