ERISA Disability Appeals

If your disability insurance policy was provided by a private employer, your policy and any claim filed thereunder is likely governed by a federal law called ERISA. 

If you have found yourself in the unfortunate position of having to apply for disability benefits under your ERISA governed policy, you might encounter a complicated and frustrating process when trying to obtain benefits. Not surprisingly, disability insurance claims are often denied for a variety of reasons, not all of which are valid or reasonable. So, what should you do when your insurance company denies your claim for short term or long-term disability benefits? 

The Employee Retirement Income and Security Act (“ERISA”) was originally enacted to protect employees covered under employee welfare benefit plans. This includes employees that file for disability insurance benefits under their employer sponsored insurance policies. ERISA also requires the plan administrator to provide a uniform process for appealing the denial of claims.

This means that insurance companies who provide disability insurance through private employers must adhere to the rules and procedures set forth by ERISA in administering insurance plans.

ERISA And Disability Insurance

While ERISA mandates insurance companies to provide a full and fair review of each claim, ERISA also gives insurance companies an unfair advantage over disability claimants. If you have filed a claim for disability insurance and it was denied, you have the right by law to file an appeal with the insurance company. Not only is this your right, but you are also required to file an appeal to preserve any legal rights to file a lawsuit. Failure to timely submit the appeal to the insurance company would cause you to lose your right to file a lawsuit against the insurance company to recover your disability benefits. 

ERISA appeal must be reviewed and decided by someone who did not make the initial decision to deny your claim.

It is important that any ERISA appeal is done with extreme care and is prepared thoroughly. In the event that your appeal is denied, and you decide to sue the insurance company, the court most likely will only look at the evidence presented in the appeal. No new information will be considered by the court. A skilled and experienced disability claims lawyer will be able to ensure that your appeal preserves all relevant evidence which may later be examined by the court.

ERISA Appeals Process

The appeals process will start after your disability claim has been denied. Your insurance company will most likely send a letter to you outlining the reasons for the denial. They must also cite the particular terms of the policy that they are relying on to deny your claim. Finally, the letter must alert you about your right to appeal and it must describe the appeals process.

Under ERISA law, the insurance company must give you 180 days from the date of denial to file an appeal. The insurance company has 45 days to respond. They can also request two 30-day extensions if they have proper justification. By law, the insurance company must provide you with the complete case file regarding your claim free of charge. Your file might be hundreds or even thousands of pages long and contain complex medical documents that are not easily understood by non-medical professionals.

During the appeals process, you are allowed to submit documents and reports to support your claim. Don’t expect the insurance company to tell you which documents and evidence are necessary to get your claim approved though.  Since there is a limited time to file an appeal, consulting with an experienced disability lawyer early in the process is recommended in order to give you ample time to gather all of the evidence that will most likely produce a claim approval.

In certain cases, the insurance company will request that you be evaluated by an independent third-party doctor to determine if your condition prevents you from working. Typically, these doctors are not really independent, but rather have a close working relationship with the insurance company. Submitting to the insurance company’s independent doctor is not optional. The doctor will draft a report which will be included in the appeal.

Similarly, you will have the option of seeing your own doctor to help prove your claim. Your own doctor’s opinion could be especially important to procure since the third-party doctor might suggest that you are not disabled or might downplay the extent of your disability.

For additional support, it is common practice for claimants to include a personal statement in addition to letters from co-workers relating to the disability. Moreover, it makes sense to keep a pain log detailing your level of discomfort over the course of your disability. Evidencing your disability goes a long way in these cases. 

Once the insurance company has received all of your appeal evidence, a decision will be made. The standard for deciding appeals is whether or not the insurance company acted reasonably in denying your claim. It is important to remember that the person deciding your appeal will most likely be an employee of the insurance company. While this person is bound to exercise a certain level of fairness, they ultimately work for the insurance company. They are not in your corner.

In the event that your appeal is denied, you have the option of filing suit against the insurance company and taking the matter to court. 

Hiring A Lawyer to Handle Your Disability Insurance Claim

As someone suffering from an injury or illness that prevents you from working you may be dealing with an unusual amount of stress and uncertainty. Losing financial support on top of this can take its toll on the most resilient of individuals. 

The importance of an ERISA appeal cannot be overstated and taking on the task of handling the appeal on your own is not recommended without first consulting with an experienced ERISA disability attorney. 

Most claimants are unfamiliar with insurance law, so they find the claims and appeals process intimidating. Insurance companies know this and would rather that you go through the entire claims process unrepresented in order to give them the best chance of avoiding paying out on claims.

Insurance companies have lawyers and administrative staff that are under no obligation to help you get your claim approved. Further, insurance policies are legal contracts. These contracts contain terms that most people other than experienced lawyers are unfamiliar with and find nauseating to look at.

Moreover, insurance companies will have plan administrators and lawyers working on their side making sure that their bottom line is protected. They also have doctors who will review your condition and make reports that will more than likely support their decision to deny your claim. An experienced disability insurance lawyer will not only make sure that your appeal is filed timely and correctly but will also assist in getting the evidence and medical records that will give you the best chance of getting your claim approved. A disability insurance lawyer will consult with experts who will analyze your claim, make assessments on your ability to perform your job, and determine what options you have to perform similar tasks, if any.

Hiring an experienced disability insurance lawyer not only will give you the peace of mind in knowing that someone who is familiar with insurance law is fighting for you, but it also evens the odds against the insurance company’s arsenal of lawyers and claims administrators.

Victor Peña Law Will Fight For You

If you are unable to work and are relying on income from your disability benefits to pay the bills, it is essential that you consult with a disability insurance lawyer who can protect your rights and who can give you the best chance at obtaining a result that will enable you to continue to provide for yourself and your family.

Victor Peña Law specializes in disability claims and ERISA appeals. We will bring in our own medical and vocational experts to review your medical and work history and help ensure that you present the best evidence for your appeal. In the event that your appeal is denied, we will file suit against the insurance company and demand that the decision to deny your appeal be overturned.

For a free consultation, call Victor Peña Law at 954-515-5504 or contact us online to receive a call the same day.