ERISA is the federal law governing employee benefits and when a disability insurance claim is denied, ERISA requires claimants to exhaust administrative processes before taking the dispute before a federal court. Once you’ve received a denial, you’ll need to deal with the insurance company directly. The insurance company must in turn explain to you the reason for their denial. This is usually conveyed with a letter that includes a few reasons for a denial. These are typically:
- Not meeting the standard for medical disability
- Incomplete medical records
- Failing to file the claim in a timely manner
You will need to know about requirements under ERISA and potential hazards that lie ahead with disability insurance claims. ERISA disability appeals have strict guidelines and deadlines. Keep in mind the disability insurance company is likely an adversary and is not looking out for your best interests.
In most cases, you will strictly have 180 days to file an administrative appeal of the denial. In ERISA disability claims, the administrative appeal is gravely important to your success. This appeal is, as a general rule, the only opportunity you have to submit proof of your disability into the administrative record and then, if necessary, into evidence for federal court. Thus, the appeal has a “dual audience” potentially – with the Federal Judge being the second audience if needed.
As a result, this is likely THE critical point for your future success of your claim, as the ONLY evidence generally considered at trial will be materials put into the record during the administrative appeal. Without a lot of additional litigation, you likely will not be able to submit more information if the case goes to federal court. Therefore, it is important to “load the record” with as much medical and vocational evidence favorable to your claim as possible and to develop all of your supportive arguments.
Medical and vocational evidence of disability is generally in the form of:
- Medical opinion evidence
- Vocational expert reports
- Objective medical testing
- Residual functional capacity reports
- Job description evidence under the federal government’s Dictionary of Occupational Titles
- Affidavits of the claimant and key witnesses
A critical mistake made at this level of appeal is not submitting all possible evidence. To repeat: any evidence you fail to provide during the administrative appeal will not be considered in your case as proof of your disability.
If you decide to take this on yourself, your appeal letter should be written to a very high standard. If your claim includes a poorly written, disorganized letter with spelling and grammatical errors,this can doom your claim, no matter how genuinely disabled you may be.
In addition, a strong appeal letter will include:
- Clear, concise information about you, the ERISA plan in question, and your claim that had been denied.
- A specific summation of your appeal and the decision or decisions you are contesting.
- A precise statement as to what you hope to achieve through the appeals process.
- A straightforward explanation of why you are appealing the decision, including all relevant facts and details.
- An introduction to the evidentiary documents included in your appeal.
- Create a table of contents so information can be easily found
- A conclusion that summarizes your points and expresses gratitude for the consideration of your appeal.
While you will want the letter to be concise, avoiding unnecessary details and undue repetition, you also want to make sure that it is comprehensive. Don’t leave important out details simply because you want to keep your letter brief. Remember this is your best chance to explain your claim. If your appeal is denied and you decide to pursue ERISA litigation, the appeal letter will be the closest thing to an opening statement that you will be afforded.
Ask your treating physician, specialists, physical therapists and any healthcare provider involved in your treatment and recovery and ask them to relevant documentation for the appeal. Make sure your doctor understands exactly why you need this information, so they write office notes that detail your disabling condition(s) which will support your claim and appeal.
If the denial letter includes inaccurate information, be sure to address it Phrasing matters in these documents. If you disagree with the language or the implication of the language, make sure to highlight that in the appeal and explain why.
It’s possible there are legal errors in the denial. We know from long experience that having an experienced ERISA appeals lawyer read both the denial letter and the claim file to identify misapplication of the law will be of great value to protecting your claim.
Be thorough and include details from the denial that you dispute and be able to back up your argument with the documentation you collected. Don’t assume the insurance company will find the needle in the haystack. Your job – or your attorney’s job – is to show them every possible detail in as clear a manner as possible.
If the insurer’s issue isn’t the injury itself, but your ability to return to work, explain precisely why you can’t work due to your condition. They have no idea what your job entails. If there’s a specific activity that you’re unable to perform, go into detail about the activity, the necessity of the activity in performing your job, and how your condition makes performing that activity impossible.
Don’t exaggerate anything. Any exaggerations will hurt your claim’s chance of succeeding. The insurance company deals with thousands of these cases and can often figure out when the facts are unsupported by what is reported. You should consider asking your doctor to write a report to describe your condition in an objective, clinical way.
You are entitled to a copy of your complete long-term disability claim file. Without it, you will not have enough information, which will put you at a serious disadvantage. You’ll need more than just the short description in your denial letter. Contact the insurance adjuster on the denial letter and tell them you are going to appeal their decision and to provide you with the complete file. Document your request and be aware you are now on a deadline to get your appeal prepared and submitted.
Once you get the file, review it carefully to try and understand why the claim was denied in the first place. Take notes. Look for missing details or omitted medical reports. Was the denial was based on lack of medical documentation, surveillance showed that you were not disabled in their view, or were mistakes made on the insurance company’s part?
Documents can get lost in the shuffle and it’s not the insurance company’s job to chase down information. In fact, it’s their job to make sure they don’t pay out one more penny than necessary. It’s your job—or your attorney’s job—to protect yourself by getting all of the documents in order.
Make sure to get all documents from your medical providers. This includes your primary care physician, psychologist, and any specialists that have been instrumental in your treatment process. Medical documentation contains essential information to support your claim and directly contradict denial reasons.
Was something in the claim file misinterpreted? Did the claims adjuster miss something major or minor that led to the denial? Gather the supporting documentation that clarifies any misunderstandings. Once you’ve done your due diligence to understand the denial and gathered and reviewed the documents that can make
Understanding the ERISA Appeals Timeline
ERISA claim appeals are complex because they often involve medical and/or vocational judgments or legal interpretations of policy terms. The regulations which govern these ERISA claims, issued by the U.S. Department of Labor give highly specific requirements for appeals. The goal of the regulations were created to protect employees, but they have become a significant impediment instead to making the process fair.
ERISA appeals are complex and require knowledge of the process by an experienced disability attorney. Navigating this on your own is extremely difficult and success is not likely. With an attorney’s representation, you’ll be far more likely to succeed. They will leverage vast experience to know how to gather the documents, put them in a format claims adjusters understand, gather any outstanding evidence and craft winning arguments to overturn unjustified denials or terminations of long term disability insurance claims. The sooner an attorney is brought onto the case, the better they can protect you and help with the process.
We have seen what happens when people wait until they receive a denial, or worse, try to handle their appeal on their own. It’s too important a matter to try without experience and professional help.
