Facing a denial for a disability, health, or life insurance claim can be overwhelming—especially when your benefits are governed by a federal law called ERISA. Many California workers rely on employer‑sponsored insurance plans for peace of mind, but when a claim is denied, the process for fighting back is complex and requires specialized knowledge.
At Kantor & Kantor, LLP, our attorneys have helped countless Californians overcome ERISA denials and secure the benefits they deserve. Here’s what you need to know about ERISA, why claims are often denied, and how our team can help.
Facing an ERISA denial? Contact Kantor & Kantor, LLP online or call us at 818-886-2525 for a free consultation.
Key Takeaways: ERISA Denials for California Workers
- ERISA governs most employer‑sponsored health, disability, and life insurance plans and sets strict rules for filing claims and appeals.
- Common reasons for ERISA denials include lack of objective medical evidence, missed deadlines, disputed policy language, and file‑only medical reviews.
- The internal appeal process is your critical opportunity to submit new evidence—once a lawsuit is filed, no new evidence can be added to the record.
- Most plans allow 180 days from the date of denial to file an appeal; missing that deadline can forfeit your rights entirely.
What Is ERISA?
ERISA stands for the Employee Retirement Income Security Act of 1974. It is a federal law that sets minimum standards for most private employer‑sponsored health, disability, and life insurance plans. ERISA was created to protect workers’ rights and ensure that employees receive the benefits promised by their employers—but it also gives insurance companies and plan administrators significant power and sets strict rules for appealing denials.
What Plans Does ERISA Cover?
ERISA covers most employer‑provided group benefits, including long‑term and short‑term disability insurance, group health insurance, life insurance, accidental death and dismemberment (AD&D) insurance, and some retirement plans. It does not apply to Social Security or government employee plans.
Why Are ERISA Claims Denied?
Even with ERISA’s protections, insurance companies frequently deny legitimate claims. The most common reasons include:
- Lack of objective medical evidence: Insurance companies often demand clear, objective proof of disability or illness—such as lab results, imaging, or physician notes. Claims that rely heavily on self‑reported symptoms or subjective complaints like pain or fatigue are more likely to be denied.
- Missed deadlines or incomplete paperwork: ERISA imposes strict deadlines for filing claims and appeals. Missing a deadline or failing to submit required forms and supporting documents can result in an automatic denial.
- Disputes over policy language: Insurance companies may interpret key policy terms—such as “disability,” “own occupation,” or “pre‑existing condition”—in ways that favor denial. Exclusions or limitations in the plan may also be cited.
- Surveillance or social media evidence: Insurers may use surveillance footage or social media posts to argue that your daily activities are inconsistent with your claimed disability.
- Medical reviews by plan doctors: Plan administrators often rely on doctors who never examine you but simply review your file and issue opinions that downplay your impairments.
- Administrative errors: Mistakes in paperwork, lost documents, or miscommunication between your doctors and the insurer can all contribute to a denial.
Understanding the common reasons ERISA claims are denied in California can help you identify whether your denial was proper and what evidence may strengthen your appeal.
Why Californians Trust Kantor & Kantor, LLP
When you’re facing an ERISA denial, experience and focus matter. Kantor & Kantor, LLP is one of California’s leading insurance law firms, devoted exclusively to representing policyholders and beneficiaries.
- Specialized focus: We practice only insurance law—including disability, health, life, and ERISA claims.
- Proven results: Our attorneys have helped recover millions of dollars for clients denied benefits.
- Personalized service: We take the time to understand your story and tailor a legal strategy to your needs.
- Reputation for integrity: We are recognized by our peers and clients for honesty, skill, and results.
- No fee unless we win: We work on a contingency basis—if we don’t recover benefits, you owe nothing.
ERISA Denials FAQs
What should I do if my ERISA claim is denied?
Request a copy of your complete claim file and denial letter, then contact an experienced ERISA attorney immediately. Strict appeal deadlines often apply and missing them can forfeit your rights.
Can I submit new evidence on appeal?
Yes, but only during the plan’s internal appeal process. Once a lawsuit is filed, no new evidence can be added to the record. It is vital to submit all supporting medical and occupational evidence with your appeal.
How long do I have to appeal an ERISA denial?
Most plans provide 180 days from the date of denial to file an appeal, but check your denial letter and policy for specific deadlines. Review your adverse benefit determination letter carefully for plan‑specific timelines.
Can I sue my insurance company if my appeal is denied?
If your internal appeal is denied, you may file a lawsuit in federal court. However, ERISA lawsuits are very different from regular lawsuits and require deep legal knowledge to pursue successfully.
How can Kantor & Kantor help with my ERISA denial?
We review your policy and denial letter, gather medical and vocational evidence, prepare persuasive appeals, and file suit in federal court if necessary. Learn more about when to hire an attorney for an ERISA claim denial.
How Kantor & Kantor Can Help with Your ERISA Denial
If you’re a California worker facing an ERISA denial, you don’t have to fight the insurance company alone. Kantor & Kantor, LLP will analyze your policy, develop the strongest possible appeal, and advocate for your right to the benefits you’ve earned.
Contact us today for a free consultation. Let us help you get the benefits you deserve, so you can focus on your health and your future.
Don’t face an ERISA denial alone. Contact Kantor & Kantor, LLP online or call us at 818-886-2525 to discuss how we may be able to help you secure the benefits you’ve earned.
