When you have been denied the insurance benefits you depend on, it can feel like your world is turned upside down. You have been paying into a system, trusting that it would support you when you need it most, but, instead of support, you are met with a denial letter.
The Employee Retirement Income Security Act (ERISA) is complex. It often seems like the law favors employers and insurance companies, leaving employees at a disadvantage when disputes arise. ERISA governs your employee benefits, including health, life, and disability insurance, setting the standards for how these benefits are administered and protected.
These benefits are designed to protect you in times of need. But when a claim is unfairly denied, delayed, or terminated, it can feel like the very support system you have relied on has been taken away.
At Kantor & Kantor, our practice includes a focus on ERISA claims. We understand the nuances of ERISA law and use our knowledge to cut through the red tape that might be holding your benefits just out of reach. With decades of combined experience in ERISA law, our team has an extensive track record of successfully challenging denied claims and navigating the appeals process. We have fought against all major insurance companies, and we understand their tactics. Our expertise and aggressive advocacy ensure that our clients’ rights are protected, and their benefits secured.
Contact us at 818-886-2525 to request a free consultation and let us take the legal burden off your shoulders. We are people helping people, and we will fight for your ERISA benefits.
What Is ERISA?
ERISA stands for the Employee Retirement Income Security Act, a federal law passed in 1974 designed to protect individuals participating in employee benefit plans.
ERISA was originally created to make sure that employees get the pension benefits promised by their employers. The law now applies to all employee benefits. Among other things, ERISA sets strict standards for the management and operation of these benefit plans. This means employers and insurance companies are supposed to act in the best interests of plan participants and follow specific rules to avoid conflicts of interest.
ERISA establishes rights and protections for employees, such as:
- Access to Plan Information: Employees have the right to know what benefits are covered, how to qualify, and the rules for claiming them. Plan administrators must regularly provide clear and accessible information about the benefits.
- Setting Standards for Fiduciaries: Fiduciaries are the people responsible for managing and overseeing the plan. Under ERISA, they must act with loyalty and care toward the employees and can face penalties if they do not act in the participants’ best interests.
- Providing an Appeals Process: If a claim for benefits is denied, ERISA requires that there be a fair appeals process. This allows participants to challenge decisions, making it possible to correct errors or wrongful denials before taking further legal steps.
While insurance companies play a significant part in claim denials, the main culprit behind many insurance denials is ERISA.
ERISA significantly impacts your ability to challenge insurance denials. Outside of ERISA, if an insurer wrongfully denies a claim, they could be held liable for emotional distress, consequential damages, and even punitive damages. However, ERISA limits the remedies available. Under ERISA, the only redress available for a wrongful claim denial is the grant of benefits owed to you and, in some cases, attorney’s fees. This lack of accountability creates little incentive for ERISA-governed insurance companies to properly pay out claims.
Understanding how ERISA affects your health, life, or disability insurance is crucial if you are facing a claim denial. At Kantor & Kantor, we focus on helping individuals navigate ERISA and other insurance-related issues.
Why Insurance Companies Deny ERISA Claims
Insurance companies do not stay in business by paying out every claim. Even when benefits are owed, they often look for ways to deny payments. Under ERISA, they have broad discretion, and, unfortunately, they sometimes use it to prioritize profits over people.
Here are some of the most common tactics we see:
1. Incomplete Documentation
Claims often require comprehensive documentation, such as detailed medical records, employment records, or proof of treatment. Incomplete or insufficient documentation can lead to a denial if it fails to substantiate the claim according to the plan’s requirements.
2. Exclusions and Limitations
ERISA plans often include specific exclusions and limitations. Common exclusions might include pre-existing conditions, certain types of treatment, or injuries occurring under specific circumstances. If a claim falls into any of these exclusions, it can be denied, regardless of the claimant’s need or status.
3. Failure to Meet the Plan’s Definition of Disability
ERISA disability plans vary in how they define “disability.” Some plans require that you be unable to perform any job, not just your current job, while others require only that you be unable to perform your specific occupation. If your condition does not meet the exact wording of your plan’s definition, your claim could be denied.
4. Lack of Objective Evidence
ERISA insurers often require objective evidence, such as lab results, X-rays, or imaging studies, to confirm your disability or condition. However, some conditions—like chronic pain, migraines, or mental health issues—do not always show up in standard tests, making it challenging to meet this criterion.
5. Claim Is Deemed “Not Medically Necessary”
In health insurance claims, one of the main reasons for denial is the insurer’s determination that the treatment or service is “not medically necessary.” This is especially common with more specialized or costly treatments. Insurance companies use their own definitions and criteria to determine what is necessary and may rely on internal medical experts who do not have a full understanding of your specific condition.
6. Vocational Assessments
For disability claims, some insurers conduct a vocational assessment to determine whether there are other jobs you could perform despite your condition. These assessments can be biased, especially if they overlook your specific skills, experience, or limitations.
7. Administrative or Clerical Errors
Sometimes, denials occur due to simple errors in processing or documenting your claim. Missing paperwork, errors in claim details, or a misinterpretation of plan documents can result in wrongful denials.
What to Do After Your ERISA Case Is Denied
The first step is to understand why your claim was denied. Your plan administrator is required to provide you with a written explanation of the denial. This explanation should detail the specific reasons for the decision. It should reference the specific plan provisions on which the denial is based and describe any additional information needed to reconsider your claim. It should also inform you of your rights to appeal the decision and the process for doing so.
Next, collect all documents related to your claim and your medical condition, treatment, work history, and anything else pertinent to your case. This might include medical records, statements from your healthcare providers, employment records, and communications with your insurance company.
ERISA places strict deadlines on appeals, usually requiring you to file within 180 days of receiving your denial letter. It is important to meet with an attorney at this point. With the help of your attorney, make sure to include all relevant documents and a detailed letter explaining why your claim should be approved based on the plan terms and supporting evidence.
ERISA laws are complex to navigate without professional help. Consulting with an attorney who focuses on ERISA cases can increase your chances of overturning a denial. Our experienced ERISA attorneys can provide valuable guidance, help gather additional evidence and ensure that your appeal addresses all procedural and substantive issues noted in the denial.
Why Choose Kantor & Kantor?
We know the nuances of ERISA law. Our focus on this area of the law has allowed us to develop an understanding of the complex rules and regulations that govern ERISA claims. We have a proven track record of successfully challenging denied claims and overturning decisions through appeals and litigation.
With decades of combined experience, we have helped thousands of clients secure their ERISA benefits through appeals and litigation. Our success stories range from straightforward claim disputes to highly complex federal court cases.
Our firm achieves the best possible outcomes for our clients. We employ a strategic, results-driven approach that is designed to maximize your chances of success. From meticulously preparing your case to advocating on your behalf, our goal is to restore the benefits you rightfully deserve.
We believe every case is unique and every client deserves personalized attention. We take the time to understand your situation, crafting a strategy that aligns with your goals. You are not just another case file at Kantor & Kantor; you are a valued member of our community whom we are committed to supporting.
How We Can Help with Your Case
Our process begins with a thorough review of your case. We will examine the details of your benefit plan, the reasons for denial or delay, and any supporting documentation. This initial assessment helps us understand the strengths of your case and determine the best approach moving forward. We take the time to listen, answer your questions, and lay out a clear strategy tailored to your specific situation.
ERISA requires claimants to complete an administrative appeal process before pursuing litigation. This is a critical stage that can make or break your case, as courts consider only evidence submitted during the appeal. Our ERISA lawyers meticulously prepare appeals, gathering comprehensive evidence, consulting with medical or vocational experts if needed, and crafting compelling arguments to maximize your chances of success.
Insurance companies and plan administrators may not always act in your best interest. Their goal is often to limit payouts, even at the expense of a valid claim. Our team knows how to negotiate effectively with insurers, leveraging our experience and familiarity with their tactics to advocate for a fair outcome.
If your claim remains denied after the appeal, litigation may be the next step. Our attorneys have experience in ERISA litigation, and we are prepared to take your case to court if necessary. We present a clear, evidence-backed case to the judge, arguing your right to benefits under ERISA law.
Contact Our Washington ERISA Lawyers
We have spent years helping clients in Washington get the benefits they were promised. We understand how personal these cases are. Every claim, every client, and every challenge are different.
We take the time to listen, to understand your story, and to build a case that reflects the truth of your situation. Whether you are appealing a wrongful denial or preparing to file a lawsuit, we will be there at every step.
ERISA law is technical, but your experience with your attorney should not be. When you work with us, you will get clear communication, honest answers, and a team that is truly in your corner.
If you are in Washington and your ERISA benefits have been denied, delayed, or underpaid, you do not have to go through it alone. Let us help you fight back.
Contact our Washington ERISA lawyers at 818-886-2525 to request 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]
