When you are dealing with a debilitating illness or injury, the last thing you should have to fight for is the very insurance benefits you have spent years earning and paying into. Yet under ERISA, that is exactly what many hardworking people face. This federal law, originally intended to protect employees, is now too often used as a shield for insurance companies, stripping away your right to a jury trial, blocking access to vital evidence, and limiting your ability to hold insurers truly accountable.
At Kantor & Kantor, we see ERISA for what it is: a powerful tool that insurance companies manipulate to deny valid claims and wear people down until they give up. We do not let that happen. Our team of dedicated Portland ERISA attorneys brings decades of experience and an unwavering commitment to helping people like you fight back against unfair treatment and systemic legal barriers. We are people helping people, and we look forward to helping you.
What Is ERISA?
ERISA, which stands for the Employee Retirement Income Security Act, is a federal law enacted in 1974 to protect employees’ retirement and welfare benefits. It establishes a framework of regulations governing employer-sponsored benefit plans, including health insurance, retirement plans, and disability insurance.
The original and purported intentions and purposes of ERISA were:
- To ensure transparency and accountability regarding employee benefits.
- To establish minimum standards for the operation and administration of employee benefit plans, including fiduciary responsibilities, funding requirements, and plan governance.
- To protect participants’ rights, such as the right to receive promised benefits and the right to participate and contribute to benefit plans.
- To provide remedies for violations.
However, ERISA has ultimately resulted in many unsatisfactory and unjust resolutions. ERISA carries its own set of fiduciary duties, obligations, and rules. The difference between ERISA and non-ERISA cases is that with ERISA, individuals do not possess the ability to file for the tort of violating the covenant of good faith and fair dealings. The inability to file for this tort means that individuals cannot obtain consequential damages for their losses, nor the possibility for punitive damages. This allows individuals limited, if any at all, options for ensuring that their insurance company treats them fairly. Additionally, under ERISA, common protections, such as the right to a jury trial, do not exist. Individuals will not be given the right to submit additional evidence once a trial begins, nor be given the opportunity to testify as to their medical history or their ability to work.
If an individual were to have to litigate their benefit denial in federal court, the maximum amount they could pursue is what the insurance company originally failed to pay. This practice emboldens and incentivizes insurance companies to unjustly deny legitimate claims because they do not need to fear substantial financial ramifications.
For more information about your legal options and to determine if we can assist with your case, contact our Portland ERISA lawyers at 866-779-9638.
Tactics Used by Insurance Companies to Deny ERISA Claims
While ERISA sets forth guidelines to protect the interests of employees and their beneficiaries, insurance companies sometimes employ tactics to deny or delay valid claims. Understanding these tactics is crucial for individuals seeking to secure their rightful benefits. Below are some common tactics used by insurance companies to deny ERISA claims:
1. Selective Interpretation of Plan Language:
Insurance companies may selectively interpret the language of the ERISA plan to support their decision to deny a claim. For example, an insurance company may define a person’s migraines as “self-reported symptoms,” and thus deny their claim, despite brain MRIs verifying the existence and frequency of said migraines. Alternatively, insurance companies may state that an individual’s claim is “caused” by mental health issues, when in reality they are only suffering from mental health issues because of the pain they are experiencing due to their physical disability.
In other cases, insurance companies may attempt to make unfair or improper allegations of pre-existing conditions, such as interpreting language too broadly as to capture items they are not allowed to capture. Some clauses will explicitly say you have to be disabled from the same diagnosis for the clause to apply, even if the pre-existing condition is directly related to the disabling condition.
2. Utilization of In-House Medical Experts
Insurance companies rely on in-house medical experts to review claims and provide opinions that favor denying benefits. These experts may downplay the severity of a claimant’s medical condition or argue that the treatment is unnecessary. Often, in-house medical experts will purport to know individuals better from afar than their physician does up close. These in-house medical experts are not merely biased, but are either bought and paid for, and/or repeatedly employed by these insurance companies because they produce continued denials.
3. Selective Use of Surveillance
Insurance companies may conduct surveillance on claimants to find evidence that contradicts their disability or medical condition. They may use this selective surveillance to dispute the severity of the claimant’s impairment and deny benefits accordingly. For example, insurance companies may choose to highlight a claimant’s ability to perform short spurts of activity, while not addressing the days of surveillance where the claimant remained bed bound or showed signs of pain and weakness on many more occasions than function was observed. Further, insurers will try to use activities that claimants admit to performing that in no way undermines their disability to make them appear “less disabled.”
4. Inadequate Explanation of Denial
Insurance companies may provide vague or insufficient explanations for claim denials, making it difficult for claimants to understand the reasoning behind the decision and effectively appeal the denial. Insurance companies will also leave out evidence that supports disability or undermines the denial, forcing claimants to request the claim file and find such deficiencies themselves.
Why Choose Portland ERISA Attorneys?
Choosing the right legal representation is crucial when dealing with complex matters such as ERISA claims. At Kantor & Kantor, we understand your challenges and strive to provide exceptional service and results. Here’s why you should choose us as your Portland ERISA attorneys:
- Specialization in ERISA Law: ERISA law is complex and ever-evolving. Our Portland ERISA lawyers have mastered this niche area, staying abreast of the latest legal developments to provide you with informed and effective representation.
- Experience: With decades of combined experience, our team of Portland ERISA attorneys has a deep understanding of ERISA law and a proven track record of success in handling a wide range of ERISA cases. We have represented clients in all stages of the ERISA claims process, from initial filings to litigation in federal court.
- Client-Centered Approach: We prioritize the needs and goals of our clients above all else. We understand that every case is unique, and we take the time to listen to your concerns, answer your questions, and develop a personalized legal strategy tailored to your specific circumstances. We are committed to keeping you informed and involved at every step of the process, empowering you to make informed decisions about your case.
- Results-Oriented: Our ultimate goal is to achieve the best possible outcome for our clients. Whether through negotiation, mediation, or litigation, we are relentless advocates for your rights and interests. We are not afraid to take on large insurance companies or employers on behalf of our clients, and we have a strong track record of securing favorable settlements and verdicts.
- Reputation: Over the years, we have earned a reputation for excellence in the legal community. We are proud of the numerous accolades and awards we have received, but our greatest source of pride is the satisfaction of our clients. Many of our clients come to us through referrals from satisfied former clients, which speaks volumes about the quality of our representation.
How Our ERISA Attorneys in Portland Can Help You with Your Case
Here’s how we can assist you with your case:
Thorough Case Evaluation
Our ERISA attorneys in Portland often begin by thoroughly evaluating your case. We will set aside time to understand fully what your case needs. When applicable, we will review your medical records, assess the specifics of your disability, and examine the terms of your employer’s benefit plan to build a solid foundation for your claim.
Assistance with Benefit Claims
Filing an initial benefit claim under ERISA requires precision and attention to detail. Our experienced ERISA attorneys can assist you in preparing and submitting your claim, ensuring that all necessary documentation is provided and deadlines are met. By leveraging our ERISA regulations knowledge and experience dealing with plan administrators, we can help maximize your chances of a successful claim outcome.
Appeals Representation
If your benefits claim is denied or unfairly delayed, you must understand that you can appeal that decision. Our ERISA lawyers in Portland have extensive experience handling ERISA appeals and can guide you through the intricate process. We will meticulously review the denial letter, gather additional evidence, and craft a compelling appeal on your behalf. We aim to present a strong case that persuades the plan administrator to overturn the denial and grant you the benefits you are entitled to.
Litigation Advocacy
In some cases, despite exhausting all administrative remedies, litigation may be necessary to resolve an ERISA dispute. Our skilled litigators are prepared to take your case to court if needed. We have a proven track record of success in ERISA litigation and will vigorously advocate for your rights and interests every step of the way.
Contact Kantor & Kantor Today
ERISA claims are deeply personal battles that impact your health, your livelihood, and your peace of mind. If you are facing a denial any resistance from your insurance provider, you need an advocate who understands not only the law, but the human cost of injustice.
At Kantor & Kantor, we challenge insurers head-on, exposing bad faith tactics and hold them accountable every step of the way. You deserve more than vague excuses. You deserve answers. You deserve action. You deserve justice. We are people helping people, and we look forward to helping you.
We offer a free case evaluation to discuss how our ERISA attorneys in Portland can assist you. Contact us now at 866-779-9638 for 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]
