Companies try to recruit employees in this competitive environment by using benefits packages. Generous employee benefits often lure prospective employees since these are often the same as money. Federal law requires larger employers to offer health insurance benefits. In addition, companies may offer pensions and disability insurance to help employees when they cannot earn money because they have suffered a disabling injury or illness.
Your company can only do so much to make your life easier. As good as their intentions are (employee benefits help them too by allowing them to recruit and retain talented workers), your company does not make the payments when you need to use these benefits.
Getting the benefits that you deserve often presents a challenge. Things are never as easy as they seem in plan descriptions of benefits because of the intricate legal definitions, fine print, and the usual insurance company mentality of protecting its bottom line.
Many employees find themselves needing legal assistance with ERISA benefit claims or disputes. If this happens to you, never wait to contact J. Price McNamara ERISA Insurance Claim Attorney. We have decades of experience protecting the rights of disabled employees and seeking the benefits they deserve in complex ERISA claims.
We obtained a $1,300,000 trial verdict in an ERISA accidental death and dismemberment case. This is only one example of how we fight for injured and disabled individuals, and you can learn more about our case results and legal team by contacting us directly for your free consultation.
The Employee Retirement Income Security Act (ERISA) governs employee benefits across the U.S. This law should protect workers with pension and retirement funds and govern benefits that employees receive from work.
ERISA should protect the legal rights of employees who receive benefits from work, including health insurance and disability insurance. The law tried to provide uniform procedures to handle disputes between the employee and plan administrator over coverage. However, in its quest for uniformity, Congress instituted systems that do not favor you as the employee.
The law should provide more transparency and timely processing and handling of claims. In addition, ERISA aims to provide uniformity in the appeals process. You do not qualify for ERISA on your own if your covered benefits come from your employer, you are subject to ERISA. You cannot opt into or out of the law.
Congress had intended ERISA to be the definitive statement in protecting employees after years of attempts to regulate employee benefit plans. National employers would have difficulty if their plans fell under different laws in each state.
Unfortunately, ERISA created even more uncertainty for employees and took away many rights they would otherwise have under state law. ERISA preempts many state laws, so you lose some of the ways that you can go after an insurance company for misconduct. ERISA cases are always in federal court, with unique and complex rules.
Congress amended ERISA numerous times. Thousands of pages of regulations guide ERISA’s enforcement, and judges have interpreted the law in thousands of cases. This can add to your confusion when you rely on your employee benefits. Legal interpretations of ERISA are primarily in the courts’ hands, which leaves a large body of precedent. Making things even more difficult is that the precedent can vary based on where you live (different courts of appeal).
ERISA applies to employee welfare benefit plans. Federal regulations define this term as:
“Any plan, fund, or program established or maintained by an employer or by an employee organization, or by both, which provides any of the following benefits, through insurance or otherwise.”
Some covered benefits can include:
ERISA only applies when you work for someone else putting you in the category of an employee. If you are self-employed and have purchased these policies independently, state law will apply to your claims (putting you in an arguably better legal position). Congress only intended to supersede state laws for employee benefits in its quest for uniformity.
Nearly all ERISA benefits are formal written plans. The law explicitly applies to them.
However, ERISA can cover other benefit plans if a reasonable person can figure out:
Unless it is self-funded (which is highly unlikely), businesses hand the operation of their employee benefit programs over to insurance companies and third-party claims managers. Your employer does not have the actual money to make the payouts, nor do they have the resources to administer these programs. It would cost them too much money.
Accordingly, you cannot rely on your company’s HR department to act on your behalf. They have no skin in the game, and insurance companies do not pay any heed to them. There is no substitute for an experienced ERISA lawyer when you need to fight an unfair and wrongful denial. Do not rely on your company’s HR to answer any questions about your benefits. Your employer cannot issue any binding guidance or opinions about your benefits. They are not the ones who have to write the checks.
The operation of these benefit programs is a far different story. The insurance companies that your employer pays have their own motivations that come into play. Your company makes a large payment to the insurer for the plan. The insurance company makes money off these premiums. They lose some of the money when they must make payments when you file a claim.
Every insurance company operates the same way. It does not matter what type of insurance company you are dealing with they do not want to pay claims. They will do everything in their power to make your life more difficult.
Insurance carriers do not like to pay large claims. For example, you may have a child with significant mental health issues who needs expensive inpatient care. The insurance company may look at the potential price tag and find a way to deny the claim.
Insurance companies know their costs and look for ways to reduce them. For them, paying your claim is an expense. They see the overall price tag of the claim and try to find ways to make your life more difficult. The more your claim might require them to pay, the more stringent they are.
For example, one of the main types of employee benefits is long-term disability insurance. This type of insurance pays part of your income when you develop an injury or illness that is not work-related. Long-term disability benefits are some of the hardest and most complex claims to get the insurance company to pay. They know how much these claims may be worth since you may never work again.
Long-term disability claims can replace up to 70 percent of your income if you cannot work. You should file a long-term disability claim when you have a non-work-related injury or illness that will keep you from working. These are not preexisting conditions. They happen outside of work after you start the job.
Some potentially qualifying disabilities include:
According to Guardian Life, the average long-term disability claim can last one to two years or longer. However, you are not an average person. The facts and circumstances of your case can vary significantly from the average.
Plan for the worst when you first file your claim. Not only may you never return to your job, but you may never work in any capacity again. Accordingly, your claim can be worth well over $1 million, depending on your pre-illness income and the severity of your condition.
Insurance companies will find every excuse possible to deny your claim. They have an entire infrastructure that is their way of sharpening their pencil to keep their payout expenses low.
In the insurance company’s view, the more so-called experts they have on staff, the stronger they can make their denial of your claim. They can make it sound more persuasive – both to discourage you from taking things further and give the denial a better chance of standing up in court if you challenge it.
Further, the problem is that your employer does not handle your claims themselves. They have hired plan administrators, and there are insurance companies involved. The company that wants you to have benefits has zero power beyond choosing plan administrators and insurance companies. Once they sign the contract, they cede all the power.
Insurance companies have their own doctors on staff. If you file a medical or disability insurance claim, your doctors may dispute whether you need the procedure or are disabled within the meaning of the policy. These doctors are never independent in the true sense of the word, even if they do not formally work for the insurance company. They get business from an insurance company, so they do not want to bite the hand that feeds them by giving too many opinions that will cost money.
These doctors will never see you, nor will they know anything about you other than what they want to see. The thing that works in your favor is that ERISA regulations require the insurance carrier to provide you with the reports and information it relied on when denying your claim. If they relied solely on their doctors and excluded your treating doctor’s opinion entirely, it can be grounds for a court to reverse the denial of your claim.
From your perspective, as an employee, you may be afraid to fight when you expect certain employee benefits and then receive a denial. You may have concerns about ruffling feathers at your place of work if you have conflict over your benefits.
As experienced ERISA lawyers, we can confidently tell you that you should not have any such worry. Your issue is usually not with your employer. Your plan gives you legal rights, but it is the insurance company that you must fight against, not the company that employs you. Your employer likely does not know what is happening between you and the insurance company.
You are not dealing with a user-friendly law. Congress passed ERISA to protect employee benefits. Perhaps it was an unintended consequence, but in its quest for uniformity, Congress set up a process that tilts toward the insurance company.
If you filed a claim under state law, you have some recourse against the insurance company. State law allows you to file bad faith claims against the insurance company for unacceptable and unlawful behavior. Although it is not always easy to win a bad faith claim, the mere prospect of a bad faith suit might check the insurance company’s behavior. ERISA, however, gives you no right to pursue a bad faith claim to hold the insurance company responsible for bad behavior.
ERISA makes you handle business directly with the insurance company for much of the process. You will file your claim directly with them first. The insurance company will make the initial decision about whether to grant benefits. Free from the prospect of a bad faith claim, the insurance company is often very aggressive about denying claims and forcing you to fight. They have an impression that they are playing on their home turf and have an advantage over you. To an extent, that is true, but you still have some powerful tools in your pocket.
The most powerful thing available to you is an experienced ERISA lawyer. When an insurance company denies your claim, they count on the fact that you will not challenge them and will go away quietly. They figure that you may not know your legal rights and will accept their denial as a given.
Insurance companies make money when people are afraid to speak up for their rights. They want you to be scared of rocking the boat. However, you will not have a chance of obtaining any benefits unless you are ready to stand up and fight.
Insurance companies intentionally make things as confusing as possible. There are complex plan terms that you may not fully understand. Before you can even appeal your denial, you must understand the exact language of the plan, so you can show how the insurance company took away from you something that you deserved. They usually try to rely on their superior knowledge of every word and clause of your plan. With an experienced ERISA claims attorney, they will not have more information than you.
ERISA claims can be challenging for several reasons. The insurance company has a built-in advantage over you for part of the process. Your first level of appeal for ERISA cases is directly to the insurer. The insurance company that denied your claim in the first place has a formal role in reviewing your appeal. While it does not make sense that a self-interested party with their finances at stake can ever be objective, this is what the law requires of you.
In reality, the insurance company will get a free look at your arguments during the appeals process. At the same time, you will also get a chance to see what the insurance company really thinks of your claim. They are required to share information with you about why they denied your claim. You can use this information to strengthen your claim during the appeals process.
Even though you are not counting on objectivity during the appeals process, you still need to make your case to the insurance company. Your real audience is the federal judge who will hear your next level of appeal.
While you always get your day in court, you do not go into court for an ERISA claim. These cases take place in front of a federal judge on the record. You will not get to testify or explain yourself in a physical courtroom. If you are counting on detailing your condition to the judge and showing why the insurance company was wrong, it will not happen.
Similarly, you cannot use the federal court appeal to patch any holes in the record from the insurance company appeals process. That record is the lasting file that federal courts use to review your case. How you document and craft the appeal file makes all the difference.
Your appeal file can include:
The judge will review what they see in front of them. Your lawyer may make your case in writing to the judge, you can give a written affidavit, and that is the extent of it.
One of the challenges you will face is that the judge is supposed to defer to the insurance company’s initial decision. You will have to show that the insurance company unreasonably denied your claim for benefits. Nonetheless, if your records conclusively show that you meet the plan’s definition of disabled, the insurance company likely acted unreasonably.
Therefore, how you make your case will make all the difference in the world in whether you will get benefits. You need an experienced and persuasive lawyer who knows the ERISA and how to make a case in these unique hearings. It is exceedingly difficult to take the insurance company on all by yourself. They have litigated countless ERISA claims. They have entire departments devoted to claims – specifically defeating yours and getting out of paying you what the plan promised.
The insurance companies often fight ERISA cases until the bitter end. There have been written decisions from courts where the dispute started a decade earlier, showing how far the insurance company will go to avoid paying you. Even if you win at the district court level, the insurance company may appeal the case further. You must have an attorney who is not afraid of figuratively going 12 rounds with the insurance company.
There are several points when you may need the help of an ERISA lawyer. Given the complexity of many claims, you can hire an experienced lawyer before you file. A lawyer will help you prepare the strongest claim possible, informing the insurance company that you are not afraid to get a seasoned professional for your case.
An attorney knows the documentation your file needs and how to make the strongest possible case that you deserve benefits. A strong claim file can make the difference between getting benefits when you first file and going through a contentious, lengthy, and fruitless appeal.
Insurance companies act as if you have the burden of proof to show that you meet the plan’s definitions and requirements to get benefits. The insurer will not grant your benefits claim if you do not make a compelling and persuasive case. Since claimants cannot sue an insurance company for bad faith under ERISA, they will be much more aggressive about denying claims.
An ERISA claims attorney can:
Perhaps the most important thing an ERISA claims attorney will do is to deal with the insurance company for you. Anything you say when speaking with the insurance company is fodder for them to take out of context in denying your claim.
The insurance company may bombard you with continuous letters and requests for more information. If you do not give them what they want when they want it, they may use it as an excuse to deny your claim.
Similarly, you may lose track of deadlines for your claim during the appeal. If you miss a deadline, it can cost you benefits. An experienced attorney will handle these details, allowing you to deal with your health condition and medical care.
You may find that it is better not to deal with an insurance company at all on your own. Once you file the initial claim, you may damage your case later in the appeals process if you make obvious errors. Once the insurance company locks itself into a position, you cannot easily change it, even by filing an effective appeal. An insurance company can easily deny your appeal. This happens frequently.
You certainly need an ERISA lawyer if your claim results in a denial. ERISA litigation is a complex field that requires detailed knowledge of the regulations and processes. You have limited opportunities to make your case effectively and powerfully. You must build a persuasive appeal file and have limited time to do so.
If your case goes in front of a judge, you must make iron-clad written arguments that show the judge why you deserve benefits based on the information they see. You will not get to personally tell your story to the judge, so you need someone with experience making persuasive and compelling arguments.
Even though it seems like an uphill battle to win an ERISA appeal, success is possible. Federal judges can and do hold insurance companies accountable when they have wrongfully denied your benefits, often in scathing opinions that lay bare these companies’ practices. If there is a pattern of insurance company misconduct, states may even take action against them.
From your perspective, your benefits are the most important thing. Your family relies on them for your financial future. Insurance companies do not get the final say, especially when they rely on self-interest to make decisions that affect you.
We offer free consultations to ERISA claims clients. It never hurts to speak with an attorney to learn more about your case and options, especially because the initial conversation will not cost you anything. If we are working on an appeal on your behalf, we will not receive payment for our time and services unless we succeed in your case. We only receive compensation if you win.
You stand to lose far more when you try to save money by doing things independently. Then, you may cost yourself the chance to win your case entirely. Let’s face it you rarely beat a powerful insurance company without help.
Price McNamara ERISA Insurance Claim Attorney fights for individual employees who are getting unfair and wrongful treatment from plan administrators and insurance companies. For us, the fight is personal, and we have seen family members in need of these vital coverages. We will speak with you and learn more about your case before advising you on how to proceed.
To learn more about how we can help you, call us today at (504) 420-6962 or email us through our contact page. ERISA is a complex law, and you need our experienced attorney to help you through your high-stakes claim.
Following graduation from Loyola Law School in New Orleans in 1990, Price McNamara served as a Federal Judicial Law Clerk to the Honorable John M Shaw, Chief Judge, United States District Court Western District of Louisiana.
Mr. McNamara founded the Law Offices of J. Price McNamara, and began putting his past experience to work for the injured and disabled clients he now represents against the insurance companies in personal injury and long term disability and other insurance disputes in both federal and state courts