Group/ERISA Insurance Benefit Lawsuits

A Set of Unique and Complicated Standards

By the attorneys of Disability Insurance Law Group

Most group or employer-provided insurance policies are governed by the Employee Retirement Income Security Act of 1974 ("ERISA"). 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 him or her. Unfortunately, while insurance carriers are not free to ignore their obligations under ERISA, often claimants are unaware of their rights and violations go unchallenged. If your group insurance policy is governed by ERISA, you must exhaust your administrative remedies prior to filing a lawsuit.

This means that if your claim for benefits is denied, you must file all mandatory appeals available under your policy directly to the insurance company that just denied your claim. Some group policies require only one appeal, but many require that you file two appeals prior to filing a lawsuit. Claimants should be aware that if they fail to file an administrative appeal, they will likely be barred from seeking benefits in a court of law. In short, if you do not follow the requirements of your policy, your right to file a lawsuit could be lost.

While appealing to the insurance company that already denied your claim may seem like a fruitless effort, ERISA appeals should never be taken lightly. This is because, in most circumstances, the only information that you are able to present in a lawsuit is the information provided to the insurance company during the application and appeals process. Accordingly, if your claim is denied, you are not just submitting an administrative appeal, but preparing your case for trial.

Most insurance companies never explain this to claimants and unfortunately, many ERISA-governed claims are lost because of it. Most claimants would never think of preparing to face their insurance company at trial without the help of an experienced attorney. However, by preparing their own administrative appeal, they are doing just that. If you fail to present all of the information you would normally present at trial in your appeal, you will likely never have an opportunity to do so.

The Importance of Experienced Legal Representation

The attorneys at Disability Insurance Law Group prepare our client's appeal as if we are preparing for a lawsuit. We expend the time, resources, and knowledge of the law necessary to prepare each of our client's appeals. This often includes:

  • Testimony from our clients, treating physicians, co-workers, employers and family members
  • Expert medical opinions
  • Independent Medical Examination reports that we obtain for our clients
  • Vocational rehabilitation reports and other expert reports
  • A thorough examination of our client's unique situation and the law that applies to their claim

Moreover, ERISA-governed insurance benefit cases are not submitted to a jury. Instead, a single judge makes a determination as to eligibility for benefits. This is based on the administrative record (the information gathered during the application and appeals process) and the complex federal law, ERISA. There are many situations in which additional information may come into the lawsuit, but such matters are typically fiercely fought by the insurance companies and involve highly complex legal strategies.

Accordingly, it is imperative that you choose a lawyer with sufficient experience in this area of the law. When involved in an ERISA insurance benefit lawsuit, the claimant has the burden of proving his or her case. However, at trial, the claimant is no longer attempting to prove that he or she is entitled to the insurance benefit, but often that the insurance company acted unreasonably in coming to its decision to deny benefits. This is an extremely high standard to prove. Accordingly, it is essentially that you provide ample and sufficient information during the administrative appeals process.

In many circumstances, claimants may seek and obtain attorney's fees, if they are successful in their lawsuit. However, ERISA claims have unique and complicated standards to meet before a claimant may obtain attorney's fees. Accordingly, the attorney you choose to prepare your appeal or file your lawsuit must have a thorough understanding of the law to secure your rights.

Get Legal Help in Group/ERISA Insurance Lawsuits

At Disability Insurance Law Group we are dedicated to protecting our clients' rights, preserving their legal remedies, and aggressively fighting for the benefits they deserve. We understand the process and have the experience necessary to challenge an unreasonable denial of insurance benefits. Contact our offices today to schedule a free initial consultation. We serve clients nationwide.