If your initial claim for disability benefits has been denied by your plan administrator, it is essential that you realize that, under ERISA, you cannot file a lawsuit until you have exhausted all administrative avenues of appeal. Appeal procedures differ from plan to plan; your summary plan description (SPD) will outline the exact steps you must follow to appeal your claim denial.
If you fail to follow the appeal process as defined by your plan and proceed with litigation, the court will have grounds to dismiss your case with prejudice of the claim.
By establishing such stringent requirements for filing ERISA lawsuits, insurance companies are hoping that most claimants will simply let the matter drop, even if they feel that their claims were unfairly and unreasonably denied. In reality, this happens far too often, leaving legitimately injured employees without the benefits they absolutely deserve. Claimants become intimidated by the very idea of taking on powerful insurance companies with vast legal resources, so they don’t bother to review their rights and options with a qualified lawyer. They just give up.
Don’t let this happen to you. With a skilled and reputable Louisiana ERISA lawyer such as J. Price McNamara in your corner, you can obtain the full measure of disability benefits to which you are entitled. He will make sure that you have fulfilled all of the prerequisites to filing a lawsuit according to the criteria set forth in your plan document. When the time for litigation arrives, he will prepare the strongest case possible and may even be able to reach a favorable settlement before the case reaches a federal judge. Even the biggest insurance companies tend to change their tunes once they know that the playing field isn’t tilted entirely in their favor.
Most people whose disability claims are unfairly rejected don’t fight back. Those who do fight back, however, often win.
This question is at the heart of every ERISA case, and only you can answer it. It’s a very different question from “If I file an ERISA lawsuit, can I win?” Unless you have already filed an appeal that left out vital documents and information, the answer to this question is generally “yes,” especially with qualified legal representation. But first you must decide whether filing a lawsuit is worth your time and effort.
In the vast majority of cases, the plan vests the plan administrator with full discretion over the acceptance and denial of claims, as well as over the interpretation of the plan’s terms. In these cases, the court can overturn the plan administrator’s decision only if it can be proven that the decision was made in an “arbitrary and capricious” manner. Deference must be given to the decision of the plan administrator.
If the plan administrator is not granted this discretionary authority in the official plan document, then the court will review the claim denial de novo – that is, without giving deference, or even consideration, to the insurance company’s prior decisions.
While de novo review is generally preferable for claimants, it has become rare in ERISA cases. Almost certainly, your case will not meet the requirements for de novoreview, in which case you will be waging an uphill battle. It is ultimately a battle youcan win, but an uphill battle nevertheless.
In considering whether you should pursue litigation, you must also keep in mind that ERISA does not allow claimants to recover punitive damages via the courts, nor does it allow claimants to collect compensation for breach of contract, insurance bad faith, or emotional distress. You will have the opportunity to collect the benefits to which you are entitled along with any interest accumulated and, at the court’s discretion, at least part of your attorney’s fees. Claimants who hope to receive windfalls may decide that ERISA litigation is not best suited to them.
Your summary plan description will attach strict deadlines to every part of the appeal process. While it may be possible to get an extension if you request one in writing, you will be in violation of the terms of the plan if you simply ignore the deadlines. As such, you will almost certainly be precluded from pursuing your disability benefits in a court of law.
If you would like to have your ERISA case evaluated free of charge and obligation, please contact the Law Offices of J. Price McNamara today. Attorney McNamara can advise you of your legal rights and options and help you follow the terms of your plan to the letter.
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