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 dissuades all large corporations from taking advantage of their 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, we are adept in helping individuals navigate ERISA laws to secure the benefits they deserve.
Our 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.
We are people helping people, and we will fight to get the ERISA benefits you rightfully deserve.
What Is ERISA?
The Employee Retirement Income Security Act (ERISA) 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 intention and purpose of ERISA was:
- To ensure transparency and accountability regarding pension benefits
- To establish minimum standards for the operation and administration of employee pension 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.
Over the years, ERISA’s scope was expanded to include non-pension employee benefits such as disability and health insurance. As a result, ERISA has ultimately resulted in many unsatisfactory and unjust resolutions for employees. 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 or unfairly limit 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 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 so 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.
Steps to Take After Your ERISA Claim Has Been Denied
- 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 and Claim File: You have the right to request a copy of your Plan documents from your employer as well as your claim file directly from the insurance company. 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 and the details of your case.
- 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.
- 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.
- 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.
Why Choose Kantor & Kantor for Your ERISA Case?
We know how complicated ERISA law can be, and we are here to guide you through every step of the process. From the moment you reach out to us, we make it our mission to understand your story, your needs, and the impact this claim has on your life.
What sets us apart is our unparalleled focus and experience with ERISA law. Over the years, we have helped thousands of individuals secure the benefits they deserve, and we bring that same dedication to every case we take on. We know the strategies insurance companies use to deny claims, and we have the expertise to fight back on your behalf.
We are here to guide you every step of the way, breaking down complicated legal jargon into clear, straightforward advice. We believe that the best outcomes happen when our clients feel empowered and informed.
Our attorneys are not only experienced in ERISA law but are also familiar with the tactics insurance companies use to deny claims. We know how to cut through the red tape, challenge unfair decisions, and build strong cases that stand up in court if necessary. With decades of experience and a proven track record, we have the skills and resources to handle even the most complex ERISA disputes.
Your Solutions Start Here – How We Can Help You
When you work with us, you get a team that cares about you and your case. Here is how we can help:
- 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.
- Appeals Representation: If your ERISA claim has been denied, having an attorney represent you during the appeal process is critical. Unlike standard litigation, ERISA cases do not allow new evidence to be introduced at trial if it wasn’t included during the appeal. This makes the appeal stage one of the most important parts of your case. Our team will ensure that your appeal is comprehensive, addressing the reasons for denial and maximizing your chances of success.
- Evidence Gathering: Many claimants struggle to obtain crucial evidence on their own, such as independent medical evaluations, expert reports, and specialized testing. We work to secure this critical information, ensuring your appeal is as strong as possible.
- Strategic Argument Development: Our attorneys analyze your claim, pinpoint weaknesses in the insurance company’s reasoning, and build a compelling case to overturn the denial.
- Thorough Documentation: We assist in compiling all necessary records, including medical reports, employment documents, and expert opinions, to support your claim effectively.
- Litigation Support: If your appeal is unsuccessful, litigation may be the next step. 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 benefits.
Navigate ERISA with Confidence – Contact Our Tacoma ERISA Attorneys Today
We believe that no one should have to take on powerful insurance companies or employers alone. These entities often rely on complex legal tactics and hope that claimants will give up out of frustration or confusion.
When you have an experienced ERISA attorney in your corner, you gain an advocate who will fight to make sure your voice is heard, and your rights are upheld.
We also believe in treating every client like a person. Your story matters to us, and we take the time to listen to what you are going through. We know that no two ERISA claims are alike, and we will create a personalized strategy that fits your unique situation.
If you have had a claim denied, delayed, or terminated, time is of the essence. ERISA cases have strict deadlines and missing them could jeopardize your ability to recover your benefits.
Contact our Tacoma ERISA attorneys at 818-886-2525 for a free consultation. Let us help you get back what is rightfully yours so you can focus on your health.
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]
