What is an ERISA Appeal for a Disability Insurance Claim?
If your long-term disability insurance policy is secured through your employer, it is considered an employee benefit and as such, in most cases (not governmental entities or church plans) is governed by a highly specific law known as ERISA. This is a federal law created to protect employee benefits, mostly retirement funds and employee welfare plans, from unscrupulous employers. However, at some point in the mid-1980s, long-term disability insurance benefits companies found the restrictions of ERISA could be applied to long-term disability claims to control the appeal process, reduce exposure, limit damages, and create a windfall. One company even had a memo addressing how much money would have been saved in damages if ERISA had governed the claims.
Today, an ERISA appeal of a disability insurance denial is a complex and challenging legal procedure, and one that should not be undertaken by the unsophisticated. We have had strong success with our appeals to disability insurance companies on denied or terminated ERISA disability claims. This is due to our deep experience in this highly focused practice area, our intense preparedness, and thoroughness to develop our appeal, and dedication to getting our clients the benefits they deserve. Our approach in undercutting each piece of the claim decision process has led to successful ERISA appeals for many clients and the reinstatement of their deserved benefits.
ERISA Appeals and the Administrative Process
You do not need to know everything about the ERISA appeals process, but you do need to understand how it works and why an experienced ERISA appeals attorney is critically important to defending your claim and advocating for your benefits when they have been denied or terminated by the disability insurance company. The most important thing to know is that the time limits for the appeal are extremely strict, and if the appeal is not filed within the time frame of your policy, you may permanently lose the right to appeal your claim or pursue it further in Federal Court. The other important thing to know is that the appeal creates the record for litigation, and in litigation, evidence outside of this record will not generally be considered.
Our process of ERISA appeals includes the development of a precise timeline as we manage the appeal. The client’s job is to get the ERISA denial information to us as soon as possible so we can be sure to hit all the marks on the timeline in an effective and efficient manner. Working with our clients to gather medical records and support, and working on statements to support the claim, are integral parts of the process. Securing testing where appropriate and expert opinions as needed help to supplement the submission and arguments.
If you receive a denial letter, we urge you to call our office immediately at 877-406-7883 so we can review your situation and tell you how we can help. There is no room for delay with an ERISA appeal, and the importance of beginning the appeal process early cannot be underemphasized.
ERISA Appeals and Documentation
Just as a short-term disability claim is the gateway to a long-term disability claim, the documents used in your long-term disability claim appeal are the only evidence accepted if you need to be in litigation on an ERISA challenge under ERISA 502(a). When documents are submitted for a long-term disability claim and the claim is denied, for the most part, the ONLY evidence the judge may consider for the ERISA appeal are those in the long-term disability claim file. Thus, the appeal is critical and carries a dual purpose – to ensure the record is sound for litigation – if needed.
Materials that are important to have in your ERISA appeals file include the original claim materials, all supporting medical documents, any evaluation of your occupation, testing secured, supporting statements from friends and co-workers, and other collateral evidence to demonstrate impairment. Advocacy is too important to attempt this without experienced support.
ERISA Appeals Disability Claims Documents
Our ERISA appeals preparation includes vocational expert reports when appropriate to buttress any challenges to your claim. We know the disability insurance company is going to try to prevent your claim from being paid in any way possible, and one tactic is to attempt to show that the material tasks and duties of your occupation are not what you were insured for, or that you have capacity beyond what your providers have stated or opined.
A Recent ERISA Appeals Success Story
Our 50-year-old client worked in upper management for a multi-media advertising agency as a Senior Buyer of advertising. After suffering debilitating back pain and undergoing multiple failed back surgeries, her claim was denied. Despite her extensive medical conditions and supporting documentation, the insurance company initially denied her claim. By meticulously building the appeal, coordinating with her medical providers, and presenting compelling evidence, we were able to overturn the denial. Today, she remains on claim with continued benefits.
If your disability insurance claim has been denied or terminated, call our office at 877-406-7883 to understand the time constraints and how we can assist with your ERISA appeal.