The Employee Retirement Income Security Act (ERISA) is complex. It often seems like the law favors employers and insurance companies, leaving employees at a disadvantage when disputes arise. ERISA governs your employee benefits, including health, life, and disability insurance, setting the standards for how these benefits are administered and protected.
These benefits are designed to protect you in times of need. But when a claim is unfairly denied, delayed, or terminated, it can feel like the very support system you have relied on has been taken away. At Kantor & Kantor, we understand how overwhelming this can be, and we are here to stand up for your rights, help you navigate the process, and fight for the benefits you deserve.
Large companies have legal teams focused on protecting their bottom line, and it can be intimidating to stand up to them on your own. Our ERISA attorneys in Orange County have the experience and knowledge to level the playing field, using our expertise in ERISA law to advocate for our clients’ needs.
We tailor our legal strategies to the specific circumstances and needs of each client. By maintaining close, personal communication throughout the process, we ensure that you are informed about the progression of your case.
Contact our Orange County ERISA lawyers at 818-886-2525 for a consultation. We are people helping people, and we look forward to helping you.
What Is ERISA?
ERISA stands for the Employee Retirement Income Security Act, a federal law passed in 1974 designed to protect individuals participating in employee benefit plans.
ERISA was originally created to make sure that employees get the pension benefits promised by their employers. The law now applies to all employee benefits. Among other things, ERISA sets strict standards for the management and operation of these benefit plans. This means employers and insurance companies are supposed to act in the best interests of plan participants and follow specific rules to avoid conflicts of interest.
ERISA establishes rights and protections for employees, such as:
- Access to Plan Information: Employees have the right to know what benefits are covered, how to qualify, and the rules for claiming them. Plan administrators must regularly provide clear and accessible information about the benefits.
- Setting Standards for Fiduciaries: Fiduciaries are the people responsible for managing and overseeing the plan. Under ERISA, they must act with loyalty and care toward the employees and can face penalties if they do not act in the participant’s best interests.
- Providing an Appeals Process: If a claim for benefits is denied, ERISA requires that there be a fair appeals process. This allows participants to challenge decisions, making it possible to correct errors or wrongful denials before taking further legal steps.
While insurance companies play a significant part in claim denials, the main culprit behind many insurance denials is ERISA.
ERISA significantly impacts your ability to challenge insurance denials. Outside of ERISA, if an insurer wrongfully denies a claim, they could be held liable for emotional distress, consequential damages, and even punitive damages. However, ERISA limits the remedies available. Under ERISA, the only recourse available for a wrongful claim denial is the benefits owed to you and, in some cases, attorney’s fees. This lack of accountability creates little incentive for ERISA-governed insurance companies to properly pay out claims.
Understanding how ERISA affects your health, life, or disability insurance is crucial if you are facing a claim denial. At Kantor & Kantor, we focus on helping individuals navigate ERISA and other insurance-related issues.
Common Reasons for ERISA Denials
ERISA denials can be a major roadblock for individuals seeking to access their rightful benefits. Here are some typical reasons why ERISA health, disability, and or life insurance claims are denied:
1. Incomplete Documentation
Claims often require comprehensive documentation, such as detailed medical records, employment records, or proof of treatment. Incomplete or insufficient documentation can lead to a denial, as it fails to substantiate the claim according to the plan’s requirements.
2. Exclusions and Limitations
ERISA plans often include specific exclusions and limitations. Common exclusions might include pre-existing conditions, certain types of treatments, or injuries occurring under specific circumstances. If a claim falls into any of these exclusions, it can be denied regardless of the claimant’s need or status.
3. Failure to Meet the Plan’s Definition of Disability
ERISA disability plans vary in how they define “disability.” Some plans require that you be unable to perform any job, not just your current job, while others only require you to be unable to perform your specific occupation. If your condition does not meet the exact wording of your plan’s definition, your claim could be denied.
4. Lack of Objective Evidence
ERISA insurers often require objective evidence, such as lab results, X-rays, or imaging studies, to confirm your disability or condition. However, some conditions—like chronic pain, migraines, or mental health issues—do not always show up in standard tests, making it challenging to meet this criterion.
5. Claim Is Deemed “Not Medically Necessary”
In health insurance claims, one of the main reasons for denial is the insurer’s determination that the treatment or service is “not medically necessary.” This is especially common with more specialized or costly treatments. Insurance companies use their own definitions and criteria to determine what is necessary and may rely on internal medical experts who do not have a full understanding of your specific condition.
6. Vocational Assessments
For disability claims, some insurers conduct a vocational assessment to determine whether there are other jobs you could perform despite your condition. These assessments can be subjective, especially if they overlook your specific skills, experience, or limitations.
7. Administrative or Clerical Errors
Sometimes, denials occur due to simple errors in processing or documenting your claim. Missing paperwork, errors in claim details, or a misinterpretation of plan documents can result in wrongful denials.
Steps to Take After Your ERISA Claim Has Been Denied
The first step is to understand why your claim was denied. Your plan administrator is required to provide you with a written explanation of the denial. This explanation should detail the specific reasons for the decision. It should reference the specific plan provisions on which the denial is based and describe any additional information needed to reconsider your claim. It should also inform you of your rights to appeal the decision and the process for doing so.
Next, collect all documents related to your claim and your medical condition, treatment, work history, and anything else pertinent to your case. This might include medical records, statements from your healthcare providers, employment records, and communications with your insurance company.
ERISA places strict deadlines on appeals, usually requiring you to file within 180 days of receiving your denial letter. It is important to meet with an attorney at this point. With the help of your attorney, make sure to include all relevant documents and a detailed letter explaining why your claim should be approved based on the plan terms and supporting evidence.
ERISA laws are complex to navigate without professional help. Consulting with an attorney who focuses on ERISA cases can increase your chances of overturning a denial. Our experienced ERISA attorneys can provide valuable guidance, help gather additional evidence, and ensure that your appeal addresses all procedural and substantive issues noted in the denial.
Contact our Orange County ERISA attorneys at 818-886-2525 for a consultation.
Why Choose Kantor & Kantor for Your ERISA Claim?
ERISA law is complicated, with strict timelines, technical rules, and a high burden of proof on claimants. At Kantor & Kantor, we have a focus on ERISA claims, and we know what it takes to succeed. Here is why clients throughout Orange County trust us with their ERISA cases.
Considerable Experience and Specialized Knowledge
ERISA law is complex and constantly evolving. Our attorneys are not only well-versed in ERISA regulations but also keep abreast of the latest legal developments. This understanding allows us to navigate your claim through intricate legal and administrative processes effectively.
Calculated Advocacy
Our attorneys are skilled in crafting effective strategies tailored to each specific case. Whether it is gathering the necessary documentation, working with medical experts, or preparing for a court appearance, we are thorough in our preparation and strategic in our execution.
Long-Standing Record of Success
Our reputation in ERISA law is not just built on experience—it is built on results. Our ERISA attorneys in Orange County have helped countless clients win back their benefits. We are proud of the outcomes we have achieved, and we are ready to put that same tenacity to work for you.
Personalized, Compassionate Service
We believe that no two cases are the same. Each client comes to us with a unique situation, and we tailor our approach accordingly. We take the time to listen to your story, understand your personal and financial circumstances, and develop a strategy that addresses your specific needs.
We Prioritize Accessibility
We are approachable and accessible. When you have questions or need updates on your case, our team is just a phone call or an email away. Keeping you informed and involved is a priority for us.
How our ERISA Attorneys Can Help with Your Case
Our process begins with a thorough review of your case. We will examine the details of your benefit plan, the reasons for denial or delay, and any supporting documentation. This initial assessment helps us understand the strengths of your case and determine the best approach moving forward. We take the time to listen, answer your questions, and lay out a clear strategy tailored to your specific situation.
ERISA requires claimants to complete an administrative appeal process before pursuing litigation. This is a critical stage that can make or break your case, as courts consider only evidence submitted during the appeal. Our ERISA lawyers meticulously prepare appeals, gathering comprehensive evidence, consulting with medical or vocational experts if needed, and crafting compelling arguments to maximize your chances of success.
Insurance companies and plan administrators may not always act in your best interests. Their goal is often to limit payouts, even at the expense of a valid claim. Our team knows how to negotiate effectively with insurers, leveraging our experience and familiarity with their tactics to advocate for a fair outcome.
If your claim remains denied after the appeal, litigation may be the next step. Our attorneys have experience in ERISA litigation, and we are prepared to take your case to court if necessary. We present a clear, evidence-backed case to the judge, arguing your right to benefits under ERISA law.
Contact our Orange County ERISA Attorneys Today
ERISA cases are known for their complexity, with layers of regulations and hurdles that can make the process feel almost impossible to navigate alone. Our team is committed to ensuring that each of our clients feels heard, respected, and supported.
When you work with us, you will receive direct access to our attorneys, so you are never left wondering where your case stands. We make it a point to explain each step clearly and to keep you informed about the strategy and progress of your case.
If you are ready to take the first step toward reclaiming your benefits, contact us today. We are here to answer your questions, provide guidance, and offer a clear path forward.
Contact our ERISA lawyers in Orange County at 818-886-2525 for a consultation.
Attorney Glenn R. Kantor
Glenn Kantor is a founding partner of Kantor & Kantor LLP. As a young attorney, Glenn saw the injustice of wrongful insurance denials and created a law firm to represent individuals seeking to obtain their rightful benefits. Glenn is committed to ensure that clients receive the benefits they are entitled to under their insurance policies or group health plans. [Attorney Bio]
