Filing an Employee Retirement Income Security Act (ERISA) disability lawsuit typically begins after an insurance company denies your claim and the administrative appeals process fails.
First, your attorney will review the denial and all relevant documents, including medical records, to determine if the insurance company made its decision properly. Then, your lawyer can file a lawsuit in federal court, presenting your case based on the administrative record.
Unlike other types of lawsuits, courts decide ERISA cases on written evidence rather than a trial. That’s why you need a lawyer from the beginning, to file your initial application with the long-term disability insurance company. Failing that, hire a lawyer to file your administrative appeal. Doing so will ensure you collect and present all of the documentation you need to win the benefits you deserve.
If you fail to submit important evidence at these stages, you cannot do so later.
A skilled ERISA attorney can handle this complicated process, filing all filings timely and accurately, and they will advocate for you in court to secure the benefits you deserve. Their legal knowledge and experience can significantly improve your chances of success.
Qualifying for ERISA Disability Benefits
To qualify for ERISA disability benefits, an individual must meet specific requirements based on the terms set out in their employer’s benefits plan. ERISA is a federal law that regulates how private employers handle employee benefit plans, including disability benefits.
Understanding the complicated steps of qualifying can help individuals navigate it more effectively:
- Check Your Employer’s Disability Plan – The first step in qualifying for ERISA disability benefits is to understand the specific provisions of your employer’s disability insurance plan. These plans can vary widely between companies, so review the plan document with a lawyer to see what conditions qualify as disabilities, how long benefits last, and the application procedure. The plan will also specify whether it provides short-term or long-term disability benefits and whether it is a self-funded or fully insured plan.
- Meet the Definition of Disability – Most ERISA disability plans define disability as the inability to perform the duties of your occupation due to illness or injury. However, the definition can vary, so carefully review the plan’s description. Some plans define disability as being unable to perform the duties of your current occupation, while others may define it more broadly as an inability to work in any occupation. The more specific the definition of disability, the more challenging the case.
- File a Claim for Benefits – Once you review your plan and confirm that you meet the definition of disability, file a claim. ERISA requires that your employer’s plan give you a reasonable amount of time to submit the claim – usually between 30 to 180 days. Your claim must include documentation of your disability, such as medical records, test results, and statements from your doctor.
- Appeal If Denied – If the insurer denies your claim, you can appeal the decision. ERISA provides a structured process for appealing a denial, including the opportunity to submit additional medical evidence and arguments. Follow the plan’s appeal process carefully, as failure to do so can limit your options. Insurers deny many initial claims, but successful appeals can result in benefits.
- Follow the Timelines – Throughout the process, stay within the deadlines that the plan establishes for filing claims and appeals. Missing a deadline can lead to an automatic denial of your claim, regardless of its merit.
Administrative Appeals in ERISA Disability Claims
The administrative appeals process is an important part of a disability benefits claim under an ERISA policy. If your claim for disability benefits is denied, you can appeal the decision within the framework established under the plan.
- Denial of Your Claim – When you file a disability claim under an ERISA policy, the insurance company or plan administrator will review your medical records, employment history, and other relevant information. If they decide you do not meet the criteria for disability, your claim will be denied. You will receive a formal notice explaining why the insurer denied your claim, including the specific reasons and evidence they used in their decision.
- Requesting an Appeal – If the insurer denied your claim, you can appeal the decision. ERISA law requires that the plan provide you with a reasonable period to file an administrative appeal, typically 180 days (6 months). Failing to meet the deadline can result in the insurer denying your claim.
- Reviewing the Denial and Gathering New Evidence – The first step in the appeals process is carefully reviewing the denial letter. Look for any weaknesses in the insurer’s reasoning or missed evidence. During the appeal, you can submit new medical records, reports from specialists, or additional evidence that shows you are disabled according to the terms of the policy. This can include updated doctor’s statements or even testimony from other experts.
- Submitting Your Appeal – Once you have all your supporting documents, you must submit your appeal to the plan administrator. You must appeal in writing and clearly explain why you believe the denial was wrong. You should also include all relevant evidence, so organize the documents in a way that makes it easy for the plan administrator to review.
- The Plan’s Review Process – Once you submit your appeal, the insurance company or plan administrator must review it. They must conduct a full and fair review, and they cannot rely on the same person who made the original denial to review the appeal. The plan administrator has a set period (usually 45 days) to make a decision on the appeal, but this can sometimes take longer.
- Final Decision – After reviewing your appeal, the plan will issue a final decision. If the appeal succeeds, the insurer will approve your disability benefits. If the insurer denies your claim again, you may take legal action in federal court under ERISA.
Steps of Filing an ERISA Disability Lawsuit
You may need to file an ERISA disability lawsuit if the insurer denies your disability claim or unfairly handles an ERISA policy. When all attempts to resolve the claim through the administrative appeals process fail, you may need to file a lawsuit in federal court.
Here’s an overview of the steps involved in filing an ERISA disability lawsuit.
- Understand the Basis for Your Lawsuit – Before filing an ERISA disability lawsuit, you must understand why you believe it wrongly denied your benefits. Plaintiffs typically base ERISA lawsuits on claims that the insurance company or plan administrator did not properly interpret the policy terms, failed to consider all the evidence, or acted in bad faith. Unlike other types of lawsuits, ERISA lawsuits generally focus on whether the plan administrator made an arbitrary and capricious decision.
- Review the Denial Letter and Appeals Record – To prepare for the lawsuit, gather all relevant documents related to your disability claim. This includes the denial letter you received from the insurance company and any medical records, doctor’s reports, and other evidence you submitted during the administrative appeals process. Courts decide ERISA lawsuits based on the administrative record, so you’ll need organized and thorough evidence.
- Consult with an Experienced ERISA Lawyer – Consult an attorney who regularly handles ERISA cases before proceeding with a lawsuit. An experienced lawyer can explain your legal rights, assess the strength of your case, and guide you through the legal process. Many lawyers offer a free initial consultation and work on a contingency fee basis, meaning they only get paid if you win your case.
- File the Lawsuit in Federal Court – Once you decide to move forward, your attorney will file the lawsuit in a U.S. District Court. ERISA lawsuits typically take place in federal court, as ERISA is a federal law. The complaint will outline why you believe the denial of benefits was wrongful and request that the court overturn the decision and award you the benefits you deserve to receive.
- Discovery Process – After you file suit, the discovery process begins. This is where both sides exchange information and evidence. You may need to provide additional documentation, and the defendant (the insurance company or plan administrator) can present their side. In ERISA cases, however, discovery is usually limited, and the case is often decided based on the written record created during the claims and appeals process.
- Court Decision – Once both sides have presented their arguments, the judge will issue a decision. In most ERISA disability lawsuits, the judge will rule based on the administrative record without a trial. The court will typically assess whether the insurance company or plan administrator acted reasonably in denying your claim. If the court rules in your favor, it may order the insurer to pay your benefits, along with possible attorney’s fees.
With the right legal support, filing an ERISA disability lawsuit can secure the benefits you deserve.
How a Lawyer Can Help with an ERISA Disability Claim?
A skilled ERISA disability attorney can navigate the complex process of applying for and securing disability benefits under an ERISA policy. From initial claim filing to appeals and potential lawsuits, an experienced attorney offers several advantages.
Here’s how an ERISA disability lawyer can assist you with your claim.
- Understanding the Policy and Your Rights – ERISA disability plans involve specific, different rules, definitions, and deadlines for benefits. An attorney familiar with ERISA law can explain your rights and the specific terms of your employer’s disability policy. They can explain the legal requirements for qualifying for benefits, including the plan’s definition of disability and what kind of documentation you need to support your claim. Knowing the policy inside and out ensures you don’t miss important steps or deadlines.
- Helping with the Initial Claim – The first step in obtaining ERISA disability benefits is filing a claim. A skilled attorney will file your claim correctly and with all necessary documentation. They can gather medical records, doctor’s reports, and any other evidence that supports your claim of disability. An attorney knows how to present your case in the best possible light, increasing the chances of your claim being approved the first time.
- Handling Appeals – If your claim is denied, an ERISA claims attorney can guide you through the appeals process, often where claims are either won or lost. ERISA allows you to appeal a denial, and an attorney can review the denial letter to identify weaknesses or errors in the insurer’s decision. They can also assist in gathering additional medical evidence, expert testimony, or updated documentation to strengthen your appeal. An experienced attorney knows how to build a compelling case to challenge the denial and increase your chances of success.
- Litigating Your Case – If your claim is denied even after the appeals process, your attorney can file a lawsuit in federal court. ERISA lawsuits are complex and have specific legal standards, but an attorney can represent you throughout the process. They will handle all filings, meet deadlines, and argue your case based on the administrative record. In many cases, the judge will decide based on the documents and evidence submitted during the administrative and appeal stages.
- Maximizing Your Benefits – A skilled ERISA attorney also ensures you receive the full benefits you deserve. This includes helping you with issues like calculating your benefit amount or addressing concerns about long-term care, rehabilitation, or potential offsets like Social Security benefits.
An experienced ERISA disability attorney can make a significant difference in the outcome of your claim, helping you secure the benefits you need to support your financial and medical needs during a challenging time.
Contact an Experienced ERISA Disability Attorney Today
A knowledgeable ERISA disability lawyer can handle every step of the settlement or litigation process for you. Your attorney will aggressively advocate for your rights and interests and pursue the disability benefits you deserve under your employer-sponsored ERISA plan.
J. Price McNamara
Attorney
Losing my own brother, then my father and sister after long, disabling illnesses just a few months apart drove a career change for me. Before that experience, I never truly understood the place you’re in. I never understood the dramatic impact that receiving (or not receiving) the disability and life insurance benefits you paid for and counted on can have on your life especially when you need to focus on family and healing. What I experienced with my own family now drives the way I view my clients and my work, and I will never forget it!
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