You have worked hard, planning for the future and relying on your benefits to be there when needed. But when your claim is denied, delayed, or unjustly reduced, it is more than just a financial setback — it can be financially and emotionally devastating.
At Kantor & Kantor, we understand these challenges. We are not just lawyers; we are people helping people and ready to advocate for you. Our experienced San Francisco ERISA attorneys are here to stand with you, providing the legal support and guidance you need to navigate this complex process.
We know that dealing with insurance companies and administrators can feel like battling a faceless bureaucracy that does not see your struggles or hear your needs. Our attorneys have stood in the shoes of countless individuals denied their rightful benefits. We are here to understand your story, ease your burdens, and guide you through the complexities of ERISA.
Contact our Francisco ERISA attorneys at 415-943-2117 for a free consultation.
What Is ERISA and What Does It Do?
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 significant injustice for insurance claimants. 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 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.
2. Utilization of In-House Medical Experts
Insurance companies rely on biased medical experts to review claims and provide opinions that favor denying benefits. Often, 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: ERISA requires a timely appeal before you are allowed to litigate in federal court. 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. Before filing an appeal, we recommend contacting our ERISA attorneys for guidance.
- 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 may have as little as 60 days to file an appeal, while disability plans usually allow for 180 days to appeal a decision. Regardless, it is important not to delay. If your disability, life, or health insurance claim is denied, your debts could be accumulating, and it is crucial to address the denial of your claim swiftly.
For years, Kantor & Kantor has been guiding San Francisco 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?
Choosing the right ERISA attorney is more than just finding someone who knows the law—it is about finding someone who truly cares about your situation. At Kantor & Kantor, we understand that behind every case is a person who is dealing with real stress, anxiety, and uncertainty. That is why we are here to help. Here are some reasons residents in San Francisco choose us.
- Experience and Expertise: With years of specialized practice in ERISA law, our team understands the complex regulations and the tactics insurers use to deny claims. We use this knowledge to anticipate challenges and strategize effectively.
- Personal Connection: The foundation of legal success is a strong client-attorney relationship. You are not a file number to us. You are a person with a story that matters. We listen to that story and tailor our approach to your needs.
- Proven Expertise: ERISA law is complex, and our team has dedicated years to mastering it. This expertise means we know how to navigate the maze of regulations and paperwork, giving you the best possible chance to succeed.
- Successful Track Record: Our team of staff is like no other and we have a history of winning and settling cases others thought were lost causes. Our results speak for themselves, and they reflect our dedication to fighting for our clients’ rights.
- We are Relentless in Your Corner: We are not the kind of lawyers who back down when things get tough. If your claim is unfairly denied, we dig deep, gather the evidence, and push back against the insurance companies. Whether it is negotiating a settlement or taking your case to court, we are with you every step of the way, fighting for the benefits you deserve.
- Results-Focused: Ultimately, what matters most is the outcome. We are focused on getting you the results that make a difference in your life. Whether it is a successful appeal or a favorable settlement, we aim to deliver the best possible results in every case we handle.
How Kantor & Kantor Can Help
We know facing an ERISA claim denial can be emotionally and financially devastating. You are dealing with enough stress, and the last thing you need is a legal battle over the benefits you thought you could count on. Here is how we can help your case.
We Listen to You
We start by listening. We want to hear your story and understand the challenges you are facing. This personal approach helps us tailor our strategies to your needs, ensuring you feel listened to and supported throughout the process.
We Offer Expert Navigation
ERISA law is complex and constantly evolving. Our team stays on the cutting edge of legal developments to navigate these laws expertly. We will explain the process in clear, understandable terms so you always know what is happening and why.
We are Experienced Negotiators
Many ERISA cases are resolved through negotiations before they reach a courtroom. Our attorneys are skilled negotiators who know how to deal with insurers and employers. We aim to secure the best possible settlement for you, minimizing the stress and uncertainty of prolonged legal battles.
We Will Give You the Best Chance to Win at Trial
If your case does go to trial, you can be confident in our ability to represent you in court. Our attorneys have a track record of successful verdicts and settlements, demonstrating our commitment and capability to see your case through to a favorable resolution.
Talk to Our San Francisco ERISA Attorneys Today
Facing ERISA issues can feel like you are up against a mountain—complex, intimidating, and tough to climb. It is not just about paperwork and policies—it is about securing your future and standing up for your rights. That is why we dedicate ourselves to not just representing you but also supporting you personally.
We understand that clients come to us with their stories and struggles. That is why we take a personalized approach to each case, ensuring we understand your situation and tailor our strategies to meet your needs. We are people helping people, and we look forward to helping you.
Contact our Francisco ERISA attorneys at 415-943-2117 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]
