The Employee Retirement Income Security Act of 1974 (ERISA) aims to regulate employee benefit plans by providing guidelines to employers and/or insurance companies, detailing how to administer employment benefits. Though ERISA is somewhat unknown, it can have a tremendous impact on insurance benefits that serve as a core to many people’s financial life. Despite this fact, ERISA is not nearly as accessible as it should be.
While ERISA does contribute in some ways to make employees’ lives more convenient if they choose to litigate – there is a tradeoff in the sense that employees are obstructed from obtaining the compensation they truly deserve after experiencing unfair or unjust claim denials. That’s where Kantor & Kantor come in. As leading ERISA attorneys in Sacramento, we are adept in helping individuals navigate ERISA laws to secure the benefits they deserve.
Our Sacramento ERISA lawyers recognize that behind every legal case are real people with real concerns. We combine compassion with unparalleled legal expertise, bringing a human touch to the legal arena to protect your livelihood. With Kantor & Kantor, you are a name, a story, and a cause for which we are proud to fight; you are anything but a case number. We most proudly define ourselves as people helping people, and we can help you navigate the challenges of ERISA and secure the benefits you rightfully deserve. Contact us at 818-886-2525 for a free consultation.
We recognize your challenges with ERISA and offer a free case evaluation to discuss how our attorneys can assist you. Contact us now at 818-886-2525 for a free consultation.
What Is ERISA?
ERISA, the Employee Retirement Income Security Act, is a federal law enacted in 1974 to regulate employer-sponsored benefit plans and protect the interests of employees and beneficiaries participating in these plans. ERISA applies to a wide range of employee benefit plans, including pension plans, retirement savings plans (such as 401(k) plans), health insurance plans, disability insurance plans, and life insurance plans offered by private-sector employers.
The original and purported intention and purpose of ERISA was:
- 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 are not able to 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.
Tactics Used by Insurance Companies to Deny ERISA Claims
When individuals file claims for benefits under ERISA, they rightfully expect their insurance companies to honor their obligations and provide the benefits they are entitled to. However, insurance companies often employ various tactics to deny or delay ERISA claims, leaving claimants frustrated and powerless. Here 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 claimaints to request the claim file and find such deficiencies themselves.
Why Choose Kantor & Kantor?
We understand the emotional and financial hardships of a denied ERISA disability claim. We are dedicated to providing compassionate and results-oriented legal representation to navigate this complex legal landscape.
Here are some key reasons why Kantor & Kantor should be your trusted partner in your fight for ERISA disability benefits:
- Extensive and Demonstrated Expertise: Our attorneys possess deep-seated knowledge of ERISA regulations and the nuances of the disability claims process. This allows us to anticipate potential challenges and develop effective strategies to overcome them. Our track record of success in securing favorable outcomes for clients is a testament to our expertise.
- Nationally Recognized Leaders: We are recognized as leaders in the ERISA disability legal area, consistently receiving accolades and awards for our unwavering dedication to client success. This recognition reflects our commitment to excellence and consistent ability to deliver exceptional results.
- Personalized and Client-Centered Approach: We recognize the unique circumstances of each client. We take the time to understand your situation and goals thoroughly and then meticulously craft a personalized legal strategy that aligns perfectly with your needs. We are committed to ensuring your voice is heard and your rights are protected throughout the process.
- Resourceful Representation: ERISA cases often involve complex medical, legal, and procedural aspects. Our firm has the resources and network to tap into expert witnesses, medical professionals, and other resources crucial to building a robust case in your favor.
- Results-Driven Approach: We are driven by results. Our Sacramento ERISA attorneys are tenacious advocates who are unafraid to take on challenging cases. We approach each case with a determination to achieve the best possible outcome for our clients.
How Can We Help
Here’s how we can help you through every step of the process:
1. Comprehensive Case Evaluation
Our ERISA attorneys in Sacramento 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.
2. Claim Preparation and Submission
Crafting a compelling disability claim is crucial for success. We assist you in preparing a comprehensive and persuasive claim, ensuring that all necessary documentation and evidence are meticulously compiled and presented to maximize your chances of approval.
3. Navigating Procedural Requirements
ERISA imposes specific procedural requirements that must be followed precisely. Our experienced Sacramento ERISA lawyers are well-versed in these intricacies and guide you through the process, ensuring that all deadlines are met, forms are correctly filled out, and any required administrative appeals are pursued diligently.
4. Appealing Denied Claims
If your ERISA disability claim is denied, we immediately initiate the appeals process. Our team meticulously reviews the reasons for denial, gathers additional evidence if necessary, and crafts a compelling appeal to present a strong case on your behalf.
Is There an ERISA Statute of Limitations?
Although ERISA does not establish a specific time frame for participant benefit claims, such as those related to disability insurance, it is important to recognize that there are still deadlines associated with ERISA claims. ERISA follows other legal deadlines which will vary, but it is important to comply with any deadlines given to you by the insurance company and reach out to a lawyer for guidance as soon as possible after being notified of a denial.
What to Do if Your ERISA Disability Claim Is Denied
Facing a denial of your ERISA disability claim can be disheartening and frustrating. However, it’s important to remember that denial is not the end of the road. You can take steps to challenge the denial and fight for the benefits you rightfully deserve.
- Review the Denial Letter: Begin by thoroughly reviewing the denial letter. Understand the specific reasons the insurance company or plan administrator cited for denying your claim. This information is essential for building a strong appeal.
- Gather Additional Evidence: If you believe the denial was made in error or based on incomplete information, gather additional evidence to support your claim. This may include medical records, test results, statements from healthcare providers, and other relevant documentation that strengthens your case.
- Understand the Appeals Process: ERISA outlines specific procedures and timelines for appealing a denial of benefits. Familiarize yourself with the requirements outlined in your employer’s benefit plan and ensure you meet all deadlines. Missing an appeal deadline could result in losing your right to litigate the denial of your appeal, a result you want to avoid at all costs.
- Consult with an ERISA Attorney in Sacramento: Seek the expertise of an experienced Sacramento ERISA lawyer at Kantor & Kantor. Our legal team focuses on navigating the intricacies of ERISA law and can provide invaluable guidance throughout the appeals process. We will review your case, identify potential weaknesses, and develop a strategic plan to present the strongest appeal.
- Craft a Strong Appeal: Work closely with your attorney to prepare a comprehensive and persuasive appeal. Clearly articulate why you believe the denial was incorrect and provide compelling evidence to support your arguments. Address any deficiencies identified in the initial claim and present a compelling case for why your disability qualifies you for benefits.
- File a Lawsuit (If Necessary): If the internal appeals process proves unsuccessful, you can file a lawsuit in Federal court. Our experienced litigators at Kantor & Kantor will advocate for your rights, present a compelling case to the court, and pursue a favorable outcome.
When Should You Appeal the Denial of Your Claim?
ERISA regulations afford disability claimants a minimum of 180 days to file an appeal following the denial of their disability claim, provided that the plan is not self-funded or salary contingent. While many plans may provide you with 180 days, it is best to comply with any deadlines given to you by the insurer.
When facing the denial of an ERISA disability claim, delays can exacerbate an already challenging situation. For individuals grappling with disabilities that prevent them from working, financial burdens may be mounting with each passing day. Therefore, expediting the reversal of the denial is paramount to alleviating these pressing concerns and securing the benefits rightfully owed.
Contact ERISA Lawyer In Sacramento Today
If you are facing challenges with an ERISA claim, contact Kantor & Kantor today to schedule a consultation with our experienced Sacramento ERISA attorneys. We are here to provide the skilled legal representation and support you need to secure the benefits you deserve.
Contact us at 818-886-2525 for a free consultation.
