Dealing with the denial of disability, life, health, or retirement benefits under ERISA can feel like a punch in the gut. ERISA was initially created to protect employees, but through the years, it has grown into a complex framework that often seems tilted in favor of insurers and employers.
Insurance companies and administrators often count on claimants’ becoming discouraged by the complicated appeals process and strict deadlines. They rely on your lack of specialized knowledge to justify their denials, leaving you feeling powerless and uncertain about your future.
At Kantor & Kantor, we know exactly how difficult this road can be, because we have walked it with hundreds of clients. Our team focuses heavily on ERISA law and has built a reputation for fighting on behalf of individuals and families who have been treated unfairly by their benefit plan administrator.
If you find yourself fighting for your ERISA benefits, trust Kantor & Kantor to provide the legal support you need. We are ready to evaluate your case, guide you through the appeals process, or take your case to court if necessary.
Contact our Oregon ERISA lawyers at 818-886-2525 for a free 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.
Does Your Condition Qualify for ERISA Disability Benefits?
You may qualify for monthly disability insurance benefits if your doctor confirms that your condition meets the definition of disability outlined in your policy. Most ERISA policies use an “any occupation” standard, meaning you must be unable to perform the duties of any job for which you are reasonably trained, educated, or suited. Your doctor must also provide appropriate treatment for your condition.
Before benefits begin, you will need to satisfy the policy’s elimination period—a waiting period that varies between policies. Be aware that some policies exclude coverage for disabilities caused by certain activities. For instance, if your injury occurred while committing a crime (such as a DUI), your insurer may deny your claim.
Every disability policy is different. To fully understand your coverage, it is important to review your policy closely with help from a lawyer. If you are filing a claim and suspect you may be denied, contact an Oregon disability lawyer before discussing details with your insurance provider.
How Insurance Companies Deny Insurance Claims
Insurance companies are in the business of managing risk, including financial risk. Unfortunately, this sometimes results in practices aimed at minimizing payouts to policyholders through claim denials. 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 if 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 treatment, 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 require only that you 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.
What to Do if 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 any appeal 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.
Why Choose Kantor & Kantor?
When you are facing an ERISA denial, the attorney you choose to represent you is important. At Kantor & Kantor, our focus on ERISA law sets us apart, providing our clients with distinct advantages like:
Expertise in ERISA Law
ERISA claims are not just one of many types of cases we handle—they are our specialty. This singular focus means we are familiar with every nuance of ERISA legislation and recent legal precedents. Our attorneys stay at the forefront of legal strategies and updates, ensuring you receive knowledgeable and up-to-date legal advice.
A Track Record of Real Results
We have successfully handled thousands of ERISA claims, recovering tens of millions of dollars in wrongfully denied benefits. Our results speak for themselves—but more importantly, so do our clients. We have helped people across Oregon get the benefits they earned, and we are ready to help you too.
Strategic and Thorough Preparation
We believe in thorough preparation and proactive strategy. From reviewing your claim and the reasons for denial to preparing a robust appeal or litigation strategy, we ensure that every angle is covered.
Our goal is to strengthen your case to the maximum, reducing the likelihood of prolonged disputes and increasing the chances of a favorable resolution.
We Take the Burden Off Your Shoulders
Filing an appeal or taking legal action under ERISA can feel like going up against a brick wall. Insurance companies have teams of attorneys working against you. We will handle the paperwork, the deadlines, and the strategy.
How We 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 only consider 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 interest. 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 Oregon ERISA Attorney Today
We understand that ERISA laws are technical, deadline-driven, and often stacked in favor of insurance companies. That is why it is so important to have someone in your corner who knows how to push back effectively.
Every case we take is fought with a tailored strategy designed to secure the best possible outcome. Our proven track record speaks for itself, and behind each success story is a team that believes in justice and the right to fair treatment under the law.
If you are facing a denial of your ERISA benefits, contact us at 818-886-2525 to request a free 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]
