ERISA Disability Administrative Appeals

October 21, 2021 | J. Price McNamara
ERISA Disability Administrative Appeals

When you experience an injury or illness that requires you to file a disability claim, the last thing on your mind at the time might be ensuring that your application is as complete and comprehensive as possible to prevent the potential of denial. Even with the most carefully constructed disability applications, insurance companies deny legitimate claims to increase their profits. If your disability insurance claim is through an employer-provided plan, the federal law known as ERISA (Employment Retirement Income Security Act) provides you with a right to appeal the denial of your claim, however, you must do so in a very specific manner. You should always seek assistance from an experienced ERISA disability attorney who handles administrative appeals and all they entail. Read on to learn more about how your lawyer can fight for your rightful disability benefits, as well as common mistakes made in the appeals process that can lead to an ultimate denial. To discuss your specific situation, reach out to attorney at J. Price McNamara ERISA Insurance Claim Attorney as soon as possible.

How Does ERISA Apply to Most Long-Term Disability Claims?

Lawmakers originally enacted ERISA to ensure that employees receive the benefits their employers and employer-sponsored benefit providers promise, whether in terms of retirement, healthcare, or disability benefits. When an employee does not receive their disability insurance benefits in line with their plan, ERISA provides them with an official appeals process to challenge the denial. This process purports to benefit employees, but, in reality, it can make the process of receiving benefits much harder. In the U.S., about eight in ten long-term disability insurance claims fall under ERISA. With a few limited exceptions, ERISA governs all long-term disability claims that involve insurance policies or plans that come in employee benefits packages. While employees might assume they can handle their own claims, the process under ERISA can get highly complicated very quickly. Disability insurance attorneys with extensive experience can navigate the process for you and handle any appeals in line with legal requirements. Insurance companies have entire teams of highly experienced disability attorneys working to fight against claims and appeals. Having an experienced disability attorney to handle any denials or delays for you will get you the most positive outcome possible.

The ERISA Claims Process Has Three Phases

The first phase of the claims process to seek disability benefits is to prepare and file the initial claim. You file your claim with the company that provides your employer-provided disability insurance, and, unfortunately, a great many insurance companies deny valid claims. Next is the administrative appeal phase, during which a disability insurance attorney from the Law Office of J. Price McNamara can help to ensure that your appeal gets processed effectively and completely. This phase has many specific requirements you must meet set out by ERISA. Should the administrative appeal phase not succeed, your final option to collect your deserved benefits is through litigation in federal court. Often, the help of the right attorney can result in a successful administrative appeal, which means you will not have to deal with a lawsuit in federal court.

Appeals Denials Come at the Worst Possible Times

When you file a claim for your short or long-term disability coverage that your employer sponsors, you and your family are likely in a place of financial stress. An injury or illness can drain your available financial resources very quickly, and not working due to your disability means your household loses significant financial support. When you receive a claim denial, it can feel heartbreaking, but you have appeal options. You must act quickly, however, so contact a lawyer for help if you do not have one. Our ERISA disability attorneys from J. Price McNamara ERISA Insurance Claim Attorney regularly work on ERISA appeals and know how to follow all necessary steps under the law to seek the benefits you deserve. The capacity to effectively appeal your disability denial will depend on the completeness of your appeal and its compliance with the requirements put forward through ERISA. The law entitles you to appeal your claim denial, but ERISA also establishes a strict, specific process through which the appeal must proceed. The benefit of having an experienced attorney is having them step in for you and navigate the process, complying with all requirements. When must deal with a disability, you don’t need to spend the time necessary to learn the rules and procedures associated with ERISA administrative appeals. The right attorney can ensure that your appeal follows procedures exactly to ensure the efficient processing of your appeal to lead to quicker compensation.

The Administrative Appeal Phase is Especially Important

The administrative appeals phase is the most impactful period or the appeal process in terms of the outcome of your ERISA claim. This is the best opportunity for you to achieve a positive outcome on your claim, although doing so requires that you handle the process properly. Your lawyer will identify the specific deadlines to request an administrative appeal from your insurance company. They will review the reasons for the denial and present all necessary information and evidence to support your claim to the insurer. You must build a strong claim record at this stage, as this is what the court will review if you must file a federal ERISA lawsuit. When you have an attorney by your side who understands how ERISA works, it can lead to a better outcome of your case. After an initial denial, you want to achieve a positive outcome during the administrative appeal process, so you do not have to advance your case through a potentially costly and time-consuming court action.

The Insurance Company Does Not Work For You

While you might presume that the insurance company your employer chose to provide you and your fellow employees coverage works for you, the company does not have your best interests as a priority. Insurance companies work for profit, and to maximize profits, disability insurance companies will deny claims to reduce the money they have to pay out. Denying claims then requires that the claimant proceeds with the ERISA appeal, which, as we discussed above, is especially complex. This puts you at an automatic disadvantage if you do not have an attorney, as the insurance companies have teams that work full-time to oppose the paying out of your claim. Remembering that the insurance company works for profit and not for you should help to guide your initial decision to hire a disability lawyer. The same is true if a disability insurer offers you a lump-sum settlement. Quick settlements try to get you to accept an amount that might seem to cover your immediate needs but might fail to provide the ongoing future support you need. An attorney can discuss any offers or appeals with you to ensure you receive what is in your best interests.

The Decision on an ERISA Administrative Appeal is Important

We cannot overstate the importance of the ERISA administrative appeal. This required step under the law prevents lawsuits against insurance companies. While this process does not always benefit you as a claimant, you want to put your best appeal forward to give yourself the greatest chance of avoiding litigation. The right attorney will present your case in line with the processes and procedures under ERISA to seek the best possible outcome. If your administrative appeal is unsuccessful, you then only have the option of filing a federal lawsuit. If you go through the administrative appeal process and your claim still receives a denial, you might be asking, “Can’t I always build a better case and file again later?” Unfortunately, when it comes to ERISA claims, the answer is simply, “No.” The law limits the evidence you provide in your lawsuit, and you cannot simply present new evidence in court if your administrative appeal was not strong enough. This means you must present the strongest case possible during the administrative appeal. The time and effort required to assemble the best possible case for your ERISA administrative appeal can be extensive. Your focus should be on your disability and medical treatment, and not on trying to figure out how to present a strong case. Stand up to the insurance companies during your administrative appeal by hiring a top disability attorney to handle your ERISA appeal.

No New Evidence After a Failed Administrative Appeal

Many claimants who ultimately fail to succeed in their disability insurance claim do so because they undertook the ERISA administrative appeal process on their own. What is most damaging is that if you fail in the administrative appeal and then have to file a federal lawsuit, the federal judge cannot review any new evidence you did not submit during the administrative appeal. This means that your only chance to build your best case after a denial is by collecting and submitting all the relevant evidence at the administrative appeals level. This evidence becomes a part of the record that you can then present later in the federal case if one is necessary. Claimants generally don't know these rules and may fail to submit all the evidence available during the administrative appeal that could help in their case. This is why hiring an attorney as soon as possible after your disability helps to ensure the success of your claim. An attorney by your side during the initial filing will help to ensure success. If you receive a claim denial, an attorney during the administrative appeal process will ensure that they submit all the evidence in support of your case so, if necessary, it is available for you at a later time during a federal lawsuit.

Filing an Administrative Appeal Without Representation is Risky

The insurance companies use the complex process of an ERISA claim to their advantage to pursue greater profits. If you bring your claim to an appeal, the insurance company will again work to find any reason to uphold your denial. If it denies your administrative appeal, you are out of options to produce new information to support your disability claim. This commonly happens to those who fail to secure legal representation. After an administrative appeal denial, the likelihood of a non-attorney successfully filing and pursuing a federal lawsuit is even lower, underlining the value of hiring a disability insurance attorney as early as possible in the process. You want the right help from the start.

An ERISA Appeal in the Final Phase is a Federal Lawsuit

If you cannot achieve the approval of your claim initially, or through the administrative appeal process, your final option will be the filing of a case in federal court. As it might sound, it is somewhat intimidating to file a case in federal court, even for some experienced attorneys. Your attorney must follow specific policies and procedures to file your lawsuit, and all parties must follow detailed rules of federal evidence. Your lawyer must make complex legal arguments that the insurance company wrongfully denied your claim to succeed in this type of case. Failure to follow proper procedure can lead to the dismissal of your case or another adverse outcome.

Connect With an ERISA Disability Insurance Lawyer from J. Price McNamara Now

The best time to speak with an experienced ERISA attorney is before filing an administrative appeal of a denied long term disability claim. The administrative appeals process is the stage of a long-term disability claim in which many claimants fail to submit the evidence they need to win. This can preclude them from winning in court, so you must present your strongest case during an administrative appeal. But even if you have already had your administrative appeal denied, we may still be able to win your claim in federal court. Having an experienced attorney on your side as soon as possible will help bring about a positive outcome of your case, allowing you to receive the benefits you need and deserve. Reach out to one of the attorneys at J. Price McNamara ERISA Insurance Claim Attorney for a consultation to discuss your ERISA case today.
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J. Price McNamara


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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