ERISA cases can be extremely complicated and full of laws that only attorneys can understand. To help our clients understand what will happen during an ERISA claim, we compiled this information about what will happen when you file an ERISA claim.
Most ERISA claims are initiated after a formal filing. Some claims can be instated over the phone, but most require written claim forms. These claim forms usually include several pages for your employer to complete, as well as one page for your doctor’s to complete. It may also be necessary for you to gather medical records.
After your claim has been submitted your insurer will begin a claim investigation. This process can take many weeks and usually involves reviewing your claim forms, contacting parties, gathering medical, pharmacy and financial records, and verifying information. In some instances, the insurer will issue a claim decision immediately after. However, the claim process will usually takes between one and four months to complete.
Once the claim has been investigated, it will be either approved or denied. If your claim is denied the insurer will usually send you a letter detailing the reasons why your claim is being denied. By law, this letter must contain certain information. The basis for why your claim is being denied must be included, along with instructions on how to appeal.
When a claim is denied, we encourage you to seek immediate legal assistance. Claimants do not usually need a lawyer during the initial claim process. However, if your claim is denied you will need the assistance of an experienced attorney. Since the appeal process is the most important step of your claim, having an attorney that knows ERISA law is absolutely critical.
If you need to file an appeal, you must do so in writing and in timely fashion. If you fail to appeal within a reasonable time, your appeal could be denied. Additionally, your appeal is the last chance you have to submit important materials for the official record. Accordingly, only an attorney experienced in ERISA law will know how to gather the appropriate documents and speak to the people that need to be spoken with.
The purpose of your appeal is to present the best case you can to the insurance company so that it will reverse its decision and approve your denied claim. The second important part of the appeals process is to get the information you need to be on record before a court.
It is important to note that you can only file a lawsuit once all your claim appeals have been exhausted. To ensure that you have done this properly, the assistance of an experienced attorney is usually necessary. If you are initiating an ERISA case, you should be aware that your lawsuit begins by filing a summons and a complaint in a United States District Court. The filing fee for this is usually $350.00.
Once a lawsuit is started, your ERISA plan insurer will be allowed 20 to 40 days to file an official answer and any counterclaims. Counterclaims can happen when benefits have been paid under your plan, but you later received income from another source like as Social Security or Workers’ Compensation. You should know that most plans expect money that has been paid out to be reimbursed if you receive funds from such sources. Health insurance plans also contain similar offsets which allow the health insurer to recover monies when an insured receives monies from another source. These funds are often considered overpayment and it is common for your ERISA insurer to assert a counterclaim seeking recovery of these funds.
Be sure to check out our next article which will discuss Part 2 of what to expect during an ERISA claim.
J. Price McNamara has been practicing law for many years and has handled many ERISA cases just like yours. The legal team at the Law Offices of J. Price McNamara is waiting to help you with your ERISA issues, so do not hesitate to contact us. We are ready to schedule your free case review, so call us now to get started.
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