Federal ERISA law often applies to claims for long term disability insurance, life insurance, or accidental death and dismemberment insurance if your insurance coverage is part of an employee benefits plan.
When you file an ERISA insurance claim, the process typically starts with submitting a detailed claim to your employer’s insurance provider. The insurance company will review your claim and may request additional documents or medical records. If your claim is approved, you will start receiving benefits. However, if it is denied, you have the right to appeal within a strict deadline.
The appeal process involves gathering more evidence and submitting a formal request. If the appeal is also denied, you may have the option to file a lawsuit in federal court.
ERISA cases are challenging because they involve detailed laws and complicated legal terms that most people don’t deal with every day. Without an experienced ERISA claims lawyer, it can be difficult to understand your rights, gather the right evidence, and navigate the appeals process if your claim is denied.
Filing Your ERISA Claim
To start an ERISA claim, submit the required forms to the insurance company. While some claims can be filed over the phone, most require written forms. These forms usually include sections for your employer and doctor to complete. You may also need to provide medical records, financial documents, and other supporting evidence.
Claim Review
Once your claim is submitted, the insurance company will start its review. Fill out all forms accurately and provide complete information to avoid delays. Keeping copies of everything you submit will help if you need to appeal later.
This process usually involves:
- Reviewing your claim forms
- Contacting different parties
- Gathering medical, pharmacy, and financial records
- Verifying information
In some cases, the insurance company will issue a claim decision immediately after. However, the claim process can take between one and four months to finalize.
Claim Decision
After reviewing your claim, the insurance company will issue a decision. If your claim is approved, you will start receiving benefits according to your plan. If it is denied, the insurer will send you a denial letter explaining the reasons for the decision.
Receiving a Denial Letter
If your claim is denied, the insurance company will send you a letter explaining the reason for the denial. By law, this letter must include specific details, such as the exact reason for the decision and instructions on how to file an appeal. Review this letter carefully, as it outlines the steps you need to take if you want to challenge the denial.
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Appealing a Denied Claim
If your claim is denied, get legal help right away. An ERISA disability claims denial lawyer will guide you through the process. The goal of your appeal is to convince the insurance company to reverse its decision and approve your claim. Make sure all necessary information is recorded if the case goes to court.
To file an appeal, you must submit it in writing within the required timeframe. Missing the deadline could result in your appeal being denied. Your ERISA lawyer will explain in detail how the benefit claims procedure regulation applies to your situation.
Appeal Review
After you submit your appeal, the insurance company will review the additional information you’ve provided. The insurer will re-examine the facts of your case, including any new medical records, documents, or evidence you submitted. They may also contact your doctors or other involved parties for further clarification.
Appeal Decision
Once the review is complete, the insurer will decide on your appeal. They will either approve the claim, deny it again, or ask for more information. The appeal process is your last opportunity to present new evidence before potentially taking legal action.
Filing an ERISA Lawsuit
You can only file a lawsuit after all your claim appeals are exhausted. Your lawsuit begins by filing a complaint and a summons in a United States District Court. The way your lawsuit is handled will depend on the rules of the state court where your case is pending.
It is in everyone’s best interest to resolve the case quickly and efficiently. If a settlement cannot be reached, the court requires both parties to try to agree on as many procedural issues as possible.
After this, both sides will file relevant documents related to your ERISA claim with the court. Then, each party’s attorney will prepare briefs, which are written documents that clearly outline their positions on the case.
Insurer’s Response
After you file a lawsuit, your ERISA plan insurer usually has 20 to 40 days to respond. They will file an official answer to your complaint, addressing the issues you’ve raised in the lawsuit. In some cases, the insurer may also file counterclaims.
Possible Counterclaims
Counterclaims can happen when benefits have been paid under your plan, but you later receive income from another source like Social Security or Workers’ Compensation. Most plans expect money that has been paid out to be reimbursed if you receive funds from such sources.
Court Decision
Once you file an ERISA lawsuit, the case will move to a federal court, where a judge will review all the evidence and arguments from both sides. The judge will then make a decision based on the facts, the law, and the terms of your ERISA plan.
When your case is being heard and decided, an attorney cannot evaluate the merits of your case until they review the administrative record. The administrative record must be disclosed during your litigation. Unlike other types of lawsuits, ERISA cases are typically decided without a jury, meaning the judge alone will determine the outcome.
If the judge rules in your favor, the insurer may be ordered to pay your benefits, along with any other remedies the court deems appropriate. If the judge rules against you, the denial of your claim will stand. After the decision, either party may have the option to appeal the judge’s ruling to a higher court.
How Long Will My ERISA Case Take?
Once your paperwork is filed, a case can typically take between one to two years to complete. However, since there is no trial you will not appear in court. A decision will usually be rendered within 60 days after your attorney argues your case.
What Are the Typical Fees for an ERISA Case?
Lawyers and law firms have different ways of handling fees for ERISA cases. Some attorneys or firms may ask the client to pay a retainer upfront and then charge hourly fees against that retainer to manage the case.
Other firms may require an upfront retainer to cover costs but handle attorney fees through a contingency fee arrangement, meaning the lawyer’s fees are only paid if the case is successful.
Contact your attorney or firm directly to find out how the fees for your case will be handled. Regardless of what you agree to, you must be given the fees in writing and sign a form stating that you understand and agree to the fees.
Is the Recovery Award From My ERISA Case Taxable?
Any monetary reward from your ERISA lawsuit could be taxable. However, this will likely depend on a number of factors. If you pursue an ERISA lawsuit and obtain a reward, consult a qualified tax professional regarding the taxability of any proceeds from your case.
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Call an Experienced ERISA Lawyer Today
ERISA Insurance Claim Attorneys has been serving people like you since 1990. Over the years, we have built effective strategies to navigate the complex ERISA claims process successfully. Our goal is to make the process as smooth as possible and provide you with the legal support you need every step of the way.
Our law practice is dedicated to handling ERISA claims, with a focus on long-term disability, death and dismemberment benefits, and life insurance. We are here to protect your rights and help you get the benefits you need for a better life. Call today for a free claim denial review.
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