When you have worked hard and invested in a benefits plan, the last thing you expect is to be denied the support you need when you need it most. Many employees trust that their benefits will be available to help them through tough times.
Unfortunately, these expectations are often met with frustration when facing the reality of an ERISA claim denial. The complex language of insurance policies and the stringent criteria set by these plans can make the denial of a claim seem both baffling and unjust.
The impact of a denied claim extends beyond just the financial strain. It is about the stress of not knowing how you will manage your medical expenses or maintain your standard of living. It is about the frustration of having to prove, again and again, the legitimacy of your claim. It is about the emotional toll of feeling invalidated when your condition is questioned or misunderstood by insurers.
While the ERISA claims process is notoriously challenging, understanding the reasons behind denials and knowing how to approach an appeal can make all the difference. [call out]
We are people helping people, and we are ready to help you appeal your ERISA claim denial.
What Is an ERISA Claim?
An ERISA claim involves benefits provided under the Employee Retirement Income Security Act (ERISA) of 1974 , which governs private-sector employee benefit plans such as health insurance, long-term disability, life insurance, and retirement plans. ERISA was intended to set the standard for transparency and fairness in managing these plans while protecting the rights of employees.
While ERISA does provide claimants with certain protections, including the rights to access critical documents, ERISA also creates obstacles to getting your claim fairly paid. For example, you are required to file an appeal with the insurance company before you can challenge the denial in federal court.
ERISA insurers often exploit on these obstacles as well as the overall complexity of ERISA to wrongfully deny claims.
If you are uncertain about your eligibility for ERISA benefits or have had your claim unfairly denied, contact our experienced California-based ERISA attorneys.
Contact our California ERISA attorneys today at 818-886-2525 for a free consultation.
Common Reasons for ERISA Claim Denials
Denied ERISA claims can often be traced back to specific issues:
- Insufficient Medical Evidence: Many ERISA claims, especially long-term disability claims, hinge on the strength of your medical evidence. If your medical records are unclear, lack detailed support for your disability, or do not show ongoing treatment, your claim may be denied.
- Failure to Meet Plan Definitions: Each ERISA plan has specific definitions of what constitutes a disability or other condition that qualifies for benefits. If your condition does not meet the strict criteria as defined by your plan, the insurer may deny your claim.
- Pre-existing Conditions: Many disability plans have pre-existing condition exclusions. If the insurer determines that your condition existed before your coverage started, they may deny your claim on that basis, even if you believe the condition worsened after you were covered.
- Missed Deadlines: Filing deadlines for ERISA claims and appeals are strict. Missing a deadline, such as failing to provide requested information within the required time frame or not submitting an appeal within 180 days of the denial, can be a reason for denial.
- Lack of Objective Evidence: Some conditions, particularly those involving mental health or chronic pain, are subjective and do not always have clear, objective test results to back up the claims. Insurers might deny these claims if they feel the evidence is too subjective or not quantifiable.
How to Appeal an ERISA Claim Denial
1. Facing a denial? Don’t panic. You have the right to appeal—but timing and strategy are key. Here is how to start: Review the Denial Letter Carefully
Your denial letter is the starting point of your appeal. It contains crucial information, including the reasons for the denial and the deadlines for filing your appeal. Make sure you understand the specific reasons why your claim was denied and note any deadlines mentioned in the letter.
2. Gather Comprehensive Medical Evidence
One common reason for ERISA denials is insufficient medical evidence. To strengthen your appeal, collect detailed and updated medical records that support your case. This might include:
- Doctor’s notes and medical reports
- Results from recent medical tests
- Statements from your healthcare providers that address the specifics of your condition and its impact on your ability to work
- Expert opinions from third-party professionals who can provide additional insights into your condition.
3. Request Your Claim File
Under ERISA, you have the right to request your entire claim file from the insurance company. This file includes all the documents and evidence used in the decision-making process of your claim. Reviewing this file can help you understand the insurer’s perspective and identify any areas where additional evidence could be beneficial.
4. Prepare a Detailed Appeal Letter
Write a comprehensive appeal letter that addresses each of the reasons for denial listed in the denial letter. In your letter, clearly explain why you disagree with the denial and include all additional evidence that supports your case. This letter is your formal request to have your case re-evaluated, so make sure it is thorough and well-organized.
5. Submit the Appeal
ERISA regulations provide 180 days to file an appeal after receiving a denial.
Once your appeal letter and supporting documents are ready, submit them to the insurance company. Make sure to send everything by certified mail with a return receipt. This proof of mailing ensures that you have a record that your appeal was received before the deadline.
6. Speak to an ERISA Attorney
ERISA appeals are notoriously complex, and having an experienced attorney on your side can significantly improve your chances of success. At Kantor & Kantor, we know the ins and outs of the ERISA system, and we have successfully helped many clients overturn denials. We will handle the appeal process, ensuring that your case is well-documented, deadlines are met, and all legal arguments are presented effectively.
How Can an ERISA Attorney Help Me with My Denied Claim?
Our ERISA attorneys will assist you by thoroughly reviewing your denial letter. The denial letter typically outlines why your claim was rejected; however, these explanations are often vague, confusing, or misleading. We will help you make sense of the letter, identify what evidence the insurance company relied on, and pinpoint any gaps or weaknesses in their reasoning.
Once we understand the reasons for the denial, we will work with you to gather the evidence needed to strengthen your case. We collaborate with your doctors to obtain detailed medical reports, secure necessary test results, and ensure that all relevant information about your condition is included.
Timing is critical when appealing an ERISA denial. There are strict deadlines and missing them can be fatal to your claim. Our attorneys ensure that your appeal is filed promptly and within the required time frame. We manage all communications with the insurance company, making sure that nothing is overlooked.
Our experience demonstrates that we know how to build a solid administrative record that includes all the necessary documentation and arguments. This is particularly important because if your appeal is unsuccessful and your case moves to federal court, the court will often only review the evidence in the administrative record.
If the appeal is denied, we are also prepared to take your case to federal court. The process of litigating an ERISA claim is highly specialized, and it is crucial to have an attorney who understands the intricacies of ERISA law.
Our team at Kantor & Kantor has extensive experience litigating ERISA cases, and we will aggressively fight for your rights in court if it comes to that.
We are People Helping People, and We are Here for You
At Kantor & Kantor, we understand how challenging this process can be. We are people helping people, and we genuinely care about getting you the support you need. Whether you are preparing to file a claim or find yourself reeling from a denial, we will help you every step of the way.
Contact our ERISA attorneys at 818-886-2525 for a free consultation.
