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ERISA Claims and Appeal Process [Guide]

ERISA Claims and Appeal Process [Guide]

In this guide you will learn, step-by-step, how to file an ERISA claim.

Contrary to some impressions, ERISA does not guarantee you long-term disability benefits if you are either injured or become sick. The law does give you certain rights, however, and you will still need to file a claim, submit volumes of paperwork, and deal with an insurance company to get or restore your benefits. You must also meet strict requirements during the detailed claims process.

Before you even submit your application, you should hire a lawyer who understands what you need to show to qualify for benefits and the process that you must follow. You must account for the specifics of your coverage, and that requires forethought and attention.

It’s a lot to learn—so much so that you’re best off hiring an ERISA lawyer to handle everything for you.

Meanwhile, don’t confuse long-term ERISA disability benefits with privately purchased disability insurance plans. Federal law and regulations put out by the Department of Labor generally govern group benefits that your employer offers as part of your job. That’s generally not true of plans you purchase yourself.

Learn About the Requirements of Your Plan

The first thing to do when you think that you may need to apply for long-term disability is to review your exact plan. While there are minimum federal requirements, not every plan is the same. Each plan has its own rules that you must follow when presenting your claim.

Your employer might provide you with a plan booklet. If not, you can ask your employer’s human resources department for another copy of the booklet. This booklet will describe the procedure that you need to follow to file your claim and the documentation that the insurance company needs to see. In addition, you will also want to know that your specific disability is eligible for coverage. Each plan has a definition of “disability.”

Things to Consider During the Claims Process

Here are some additional tips for you to follow when you are filing an ERISA claim:

  • Gather all of your documentation – being organized helps greatly, especially when you have a limited amount of time to file your claim and even less time to appeal. The insurance company is just obligated to follow the ERISA rules and not to give you the benefit of the doubt for missing information.
  • Keep all of your communications with the insurance company – this will also be helpful when you need to hire an attorney to appeal a denial. They can get up to speed quickly in your case.
  • Check your claim closely before you file – one small mistake could make the difference between approved benefits and a denial. Even if you can correct the mistake in the appeals process, it will still cost you time and benefits.

Your Claim Needs Strong Documentation; This Is a Must

Familiarizing yourself with the process also means understanding what you will need to provide. You, your employer, and your physician will need to give statements to accompany your claim. Your statement may be the most important part of your claim. The insurance company will go over every piece of documentation with a fine-tooth comb, looking for a reason to deny or terminate the claim.

We cannot stress enough the importance of having strong documentation. It is better to err on the side of providing more documentation than less, provided that you are telling a consistent story. To the extent that you can provide additional information beyond just the required forms, you should include attachments with your claim.

Assume That the Insurer Can Watch You

In addition, you should be careful during the claims process not to be too active and to follow your doctor’s instructions. Assume that the insurance company can see your social media posts and watch you every day. If you do not follow medical instructions, you have given the insurance company another reason to deny or terminate your claim. The insurance company may even ask you about your activities. It is not paranoia to assume that someone is watching you.

If you need help with your long-term disability claim, you can have an authorized representative submit the claim for you. This could include an attorney that you hire for assistance with the process. Sometimes, it is better to get help prospectively than to run the risk of a denied application because you made a mistake.

You Need a Medical Diagnosis First

Before you submit your application, get a complete medical evaluation and diagnosis. After all, the basis of your claim is that you are disabled and cannot work. The insurance company is going to pay very close attention to what is on the paper. They will need to see a specific diagnosis that makes your condition very clear.

The insurance company has a limited amount of time to respond to your claim; 45 days to be exact. They have the right to ask for an extension if they need more information or if they just need time. They also can request that you provide more information. Then, they can have up to a 30-day extension from the time that they make the request or receive additional information.

What to Do When You Receive a Claim Denial

If they decide to deny your claim or cut off your benefits, they must be very specific about why, so you know when you try to appeal the denial. You should take their explanation to your attorney to review.

Even though your ERISA rights come from federal law, your long-term disability claim is evaluated directly by the insurance company. Federal courts do not get involved until later in the process if it is necessary. The insurance company has its own financial framework under which they operate. They will deny claims for any reason that they can, so they can avoid paying them.

Why the Insurance Company Might Deny Your Claim

Here are some reasons why an insurance company may deny your ERISA long-term disability claim:

  • They do not believe that you have a disability – each policy will have its own definition of the word. Having a disability is a requirement for coverage. The insurance company may claim that what you are suffering is not a “disability” within the meaning of the word in the policy.
  • The medical evidence does not support your claim – every claim must have support from a medical diagnosis that is evidence of the disability. You must have seen a doctor (certainly more than once) who has a valid basis for making a statement that you are disabled. In some cases, the insurance company may say that the diagnosis does not support the finding of a disability or the paperwork is missing in the first place.
  • They are aware of inconsistent evidence – never underestimate the power of an insurance company to go out of their way to get evidence to deny a claim. They could review your social media or even have someone follow you. If they think that your life and what you do is inconsistent with someone disabled, they may deny the claim.
  • The claim does not meet deadlines or paperwork requirements – These procedural requirements mean a lot, and you should take them seriously. If you make a mistake, it can lead to a claim denial.

How the ERISA Administrative Appeal Works

When an insurance company initially denies your claim, it is not the end of the road in your quest for benefits. ERISA lays out an appeals process that you must follow. If you do not already have a lawyer at this point, this is when you must hire one. The appeals process has tight deadlines, and you must do it right, so you need someone with experience in contesting claims denials.

The ERISA administrative appeal is somewhat different from the usual claims appeal because of the provisions of the law. You file the administrative appeal with the insurance company, not in court. While the insurance company does not have the final say over your claim, they do have an incredible amount of power, and it can make your life more difficult.

Ordinarily, you would sue an insurance company for improperly denying your claim or terminating your benefits. Recent changes to the federal rules allow you to sue an insurance company for their failure to follow Department of Labor guidance, although you still cannot sue them for denying your claim.

The Insurance Company Appeals Process Is Crucial

You need to take the administrative appeal seriously. It is a vital step if you are to receive benefits. If you do not fully complete every step in the process, you may lose the chance to overturn a denial.

The initial step in the appeals process happens directly with the insurance company. When you file the administrative appeal, the insurance company has the decision-making power over the first level. This is unlike a workers’ compensation claim, where the appeal goes directly to an administrative law judge.

There are very strict timelines for you to file an appeal. The deadline is generally within 180 days after you receive your claim denial. While you should take enough time to file a persuasive and compelling appeal, you also should not wait until right before the deadline to file. Since the insurance company has 45 days to decide your appeal, the quicker you file, the sooner you can receive benefits.

What the Insurance Company Must Do When Denying Your Claim

You have the right to fully understand the insurance company’s initial decision before you file the appeal. This way, you can know the arguments that you need to make to persuade the reviewer that the insurance company made a mistake. The insurance company must provide a reason for rejecting your claim. You also have the right to request the documents and information that they used in evaluating your claim.

A different evaluator at the insurance company will then review your claim, paying attention to the arguments that you have raised as to why the insurance company was wrong. During this process, the insurance company has the right to have you see an independent doctor for a medical evaluation. The person reviewing your file will read all of the documentation and information and consult with medical professionals before issuing a decision on your appeal.

Many people think that they should not take the appeals process seriously, thinking that they will not get a fair shake from the insurance company that has already denied their claim. However, the federal government requires insurance companies to use impartial evaluators at every step of the process. Whether or not that is true, there are reasons why you must.

You will need to develop a full record for your appeal. You introduce every single possible piece of evidence that you can for the insurance company’s consideration. In some cases, you may provide enough to persuade them that they should grant your benefits. Regardless, this is your only chance to develop an evidentiary record for your case. ERISA does not allow you to introduce more evidence later in the process.

Filing a Lawsuit for Claims Denial

If the insurance company denies your appeal, the next step is to take the case to federal court. You cannot file any lawsuit until you have gone through the insurance company appeals route. It is a required step.

The court will be reviewing the record from your appeal. There will not be any chance to add more to the record. They will make their decision based on whether they believe whether the insurance company made a mistake based on the record in front of them.

Suing in Federal Court

You have two levels of appeal in federal district court. The first is at the district court level. The judge will decide whether the insurance company made the correct decision without any further testimony. If you do not succeed at the federal district court level, you can take your case to an appeals court.

As you can see, an appeal requires an experienced disability attorney who can marshal persuasive arguments in a short time. They must quickly process medical information and understand how to argue that the insurance company has erred, both to the insurance company and a judge. This requires specific experience with ERISA claim lawyer.

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