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 largely unknown to insureds, it can have a tremendous impact on insurance benefits that you may eventually rely upon to protect your financial future.
Unfortunately, for claimants like you, ERISA is evil. It incentivizes bad behavior by insurance companies by stripping claimants of traditional legal damages which usually dissuade all large corporations from taking advantage of its customers. ERISA’s complex and intimidating nature compounds this problem, leaving most lawyers unwilling (and largely unable) to competently handle ERISA litigation.
That is where Kantor & Kantor come in. As leading ERISA attorneys in San Diego, we are adept in helping individuals navigate ERISA laws to secure the benefits they deserve.
Our San Diego 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 858-758-4231 for a free consultation.
Contact our San Diego ERISA attorneys at 858-758-4231 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 dealing. The inability to file for this tort means that individuals are not able to obtain consequential damages for their losses, nor is there the possibility for punitive damages. This allows individuals limited options, if any at all, 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 bedbound 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 undermine 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.
What Can I Do If My ERISA Claim Is Denied?
Having your ERISA claim denied can feel like a major setback. There are steps you can take to challenge the decision and potentially turn things around. Here is a guide on what to do next:
- Understand the Reason for Denial: The first step is to understand why your claim was denied. The denial letter should provide a detailed explanation.
- Request a Copy of Your Plan Documents: You have the right to request a copy of your insurance plan documents. These documents outline the terms of your coverage and can provide insight into why your claim was denied. Review these carefully to understand your plan’s requirements.
- Gather Additional Evidence: If your claim was denied due to insufficient evidence, gather additional documentation to support your case. This can include medical records, doctors’ notes, and any other relevant information. Make sure all evidence is clear and comprehensive.
- File an Appeal: You have the right to appeal the denial. The denial letter should include instructions on how to file an appeal and the deadline for doing so. Follow these instructions carefully. The appeals process can be complex and time-sensitive, so act quickly.
- Seek Professional Help: Consider hiring an ERISA attorney. ERISA laws are complex, and having a lawyer on your side can make a big difference. They can help you understand your rights, navigate the appeals process, and build a strong case.
When Should You Appeal the Denial of Your Claim?
You usually have at least 180 days to appeal a decision, though some plans may allow for longer periods. Regardless, it is important not to delay. If you are disabled and unable to work, your debts could be accumulating, and it is crucial to address the denial of your ERISA claim swiftly.
For years, Kantor & Kantor has been guiding San Diego residents through disputes with insurance companies. We have successfully advised and represented hundreds of clients, and we have the expertise to navigate even the most complex ERISA claims.
Why Choose Kantor & Kantor?
When you are dealing with something as important as your ERISA claim, you want to make sure you are in the best hands possible. Here is why Kantor & Kantor is the right choice for you:
Specialization in ERISA Claims
ERISA law is complex, and it demands a high level of specialization. Our team is not just familiar with ERISA; we have dedicated our practice to mastering this area of law, ensuring that we are always ahead of the latest legal developments and strategies.
Proven Success
We have a track record of successfully helping clients secure the benefits they deserve. Our past successes are a testament to our dedication and expertise. We are proud of the difference we have made in our client’s lives, and we are ready to do the same for you.
Results-Driven Approach
Our firm is motivated by a genuine desire to see you succeed. We have helped countless clients secure their rightful benefits, and our track record speaks for itself. But more than just winning cases, we are committed to achieving outcomes that truly make a difference in the lives of our clients. Whether it is recovering a denied claim or negotiating for better benefits, we are relentless in our pursuit of justice for you.
Client-Centered Approach
We see our clients as individuals with unique stories and distinct needs, not just case numbers. Our approach is to listen, empathize with your situation, and tailor our legal strategies to align with your specific circumstances and goals.
Accessibility and Support
We make it a point to be accessible and responsive to our clients. When you have questions or concerns, we are here to provide answers and offer support. You will never feel alone in your legal journey with us.
How We Can Help
Every case involves a story—a person or a family facing uncertainty about their future due to denied benefits or disputes over what they rightfully deserve. Here is how we can help bring clarity and resolution to your situation:
- Claim Evaluation: The first step in tackling your ERISA case is understanding the specifics of your situation. We will sit down with you, listen to your story, and review your claim in detail. This initial evaluation helps us identify any potential issues and develop a strategic plan tailored to your needs.
- Documentation Assistance: One of the most difficult parts of an ERISA claim is gathering and organizing the necessary documentation. We know this process can be overwhelming. Our team will assist you every step of the way, ensuring you have all the required medical records, employment documents, and other evidence needed to strengthen your claim.
- Appeals Representation: If your ERISA claim has been denied, you have the right to appeal. We are here to guide you through this complex and often time-sensitive process. We will craft an appeal that addresses the reasons for the denial and highlights the merits of your case. Our goal is to turn that “no” into a “yes.”
- Litigation Support: Sometimes, despite our best efforts, an appeal may not result in a favorable outcome. In such cases, litigation might be necessary. Our experienced ERISA attorneys are prepared to take your case to court, advocating on your behalf. We will stand by you, providing the support and representation you need to fight for your rights.
Important Deadlines
Appeal Deadline
If your claim for benefits under ERISA has been denied, you are entitled to file an appeal. Under federal law, the plan administrator must provide you with a detailed explanation of why your claim was denied, along with instructions on how to appeal. You typically have 180 days from the date of the denial letter to submit an appeal. This deadline is non-negotiable, and failing to meet it could result in a permanent loss of benefits. You should always adhere to the deadline identified in the denial letter you receive.
Deadline to File Your Lawsuit
If your appeal is denied, your next step may be to file a lawsuit under ERISA. This is known as an ERISA civil action, and it must be filed in federal court. The deadline for filing your lawsuit is governed by your state’s specific statute of limitations as well as the specific circumstances, which can vary from plan to plan. You should consult a lawyer immediately, as the best way to avoid a statute of limitations issue when filing a lawsuit is to file the lawsuit as promptly as reasonably possible.
Contact Our San Diego ERISA Attorneys Today
If you are feeling overwhelmed by the complexities of your ERISA claim, contact our ERISA San Diego attorneys. At Kantor & Kantor, we understand how stressful and confusing this process can be. Our team is here to take that burden off your shoulders. We believe that everyone deserves a fair chance to secure their benefits, and we are passionate about making that happen for you.
We know how frustrating it can be to deal with denied claims or delays, and we will fight for your rights every step of the way. Let us take on the complexities of your case so you can focus on what matters most—your well-being and future.
Contact our San Diego ERISA attorneys at 858-758-4231 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]
