If you have received health benefits from your employer, there is a good chance that your policy is governed by the Employment Retirement Income Security Act, otherwise known as ERISA. If you have recently tried to file a claim from your ERISA provider and then got denied, it does not mean that you will not eventually receive your benefits. Under ERISA law, everyone who is denied has the right to file an appeal in hopes of getting the original decision reversed. If you are planning on filing an ERISA appeal, here are a few things that you will need to do first.
1. Request a copy of Your Claim File
Before filing an appeal, you should always talk to your insurance provider and ask them for your claim file. Under federal law, they must present you with a copy of this file free of charge.
The claim file will give you a better understanding of why your claim was denied. The file will contain vital information about your case such as the medical records, doctors’ notes, and internal reviews. Once you have thoroughly reviewed this information, you will have a better idea of what type of evidence and documentation you will need to submit alongside your appeal.
2. Collect All Medical Records
Many times, a person’s claim is denied due to lack of proof that the person is disabled. Talk to your doctor and request a copy of x-rays, MRI scans, and any tests that you have had in reference to your condition. If you are seeing multiple doctors for your condition(s), be sure to gather any important records from each and every doctor that has treated you.
Sometimes, having multiple doctors agree that you have a debilitating injury or condition can help your case. While this is certainly not required, it can be a good idea to get a second opinion from another trusted doctor about your condition.
3. Take Note of Any Side Effects You are Having From Your Medications
Different medications have been known to have a wide range of side effects that could help to prove that you are eligible for benefits. For example, if you have been denied long-term disability benefits, the medications that you are required to take for your condition could make it difficult, if not impossible, to properly do your job.
Make a list of the medications that you are taking as well as the side effects that they are causing you. Also, talk to your doctor about those medications to see if you could take a different medication that would not interfere with your job performance. In some cases, your doctor may switch you to another less-harmful medication. However, many times the other medications that are available to you will have even greater risk and more severe side effects.
4. Get a Note From Your Doctor
In addition to the medical records, it is also a good idea to have a written document from your doctor that outlines your condition and helps explains why you may actually qualify to receive benefits. Make sure to not only get a letter from your primary care physician but also ask any specialists or other doctors who have treated your condition to write a letter as well. The more doctors that you have that can verify the complexity and seriousness of your condition, the better chance you have at getting a positive outcome.
5. Act Fast when Filing Your ERISA Appeal
Once your ERISA claim has been denied, you have 180 days to file an ERISA appeal. Once that time period has passed, you will not be able to file a claim anymore. Once you file an appeal, it will usually take the insurance company around 90 days to reach a decision, which means that it could take a total of 270 days before you receive a decision about your appeal. So, it is important to file the appeal as soon as possible to help make this process is completed in a timely manner.
6. Talk with an ERISA Appeal Lawyer as Soon as Possible
Being denied to receive benefits that you feel you deserve can be a discouraging and stressful time for everyone. Trying to figure out which documents are needed can be a bit confusing and add to the overwhelming amount of stress that you are already feeling. If you are planning to file an ERISA appeal, you need to contact an experienced ERISA appeal lawyer as soon as possible. An ERISA attorney will be able to review your case and walk you through the procedures and gather the information that is needed to win your case.
If you feel that the process of filing an appeal is too stressful, don’t hesitate to contact an ERISA appeal attorney. They can help take some of the burdens off of your shoulders and help you move in the right direction, which will hopefully end in you getting the benefits that you deserve.
Following graduation from Loyola Law School in New Orleans in 1990, Price McNamara served as a Federal Judicial Law Clerk to the Honorable John M Shaw, Chief Judge, United States District Court Western District of Louisiana.
Mr. McNamara founded J. Price McNamara ERISA Insurance Claim Attorney, and began putting his past experience to work for the injured and disabled clients he now represents against the insurance companies in personal injury and long term disability and other insurance disputes in both federal and state courts