Insurance companies may deny your ERISA claim because you missed a deadline, made a mistake filling out paperwork, or because you’re deemed ineligible for coverage. Insurance companies may also note limitations or exclusions in your policy as a justification for denial, which are sometimes hidden in the fine print of your policy.
In situations like these, you need to speak with an Alabama ERISA claim lawyer as soon as possible. Attorney Tom Sinclair knows how insurance companies operate, and he knows how to craft ERISA appeals suitable for both administrative remedies and a federal judge review.
Let’s explore some reasons why ERISA claims are denied and how a lawyer can help. If you need a free consultation with an experienced ERISA attorney, contact Sinclair Law Firm today. You can also reach our Birmingham law office by phone at (877) 249-0091.
Common Reasons ERISA Claims Are Denied
The reasons for a denied claim vary based on the type of benefits in question. That said, below are the most common reasons why ERISA claims are denied.
Failure to Meet Eligibility Requirements
The insurance company may claim that you technically do not meet the eligibility requirements of the policy. For cases involving denied disability coverage, the insurer may state that the injury or illness is not consistent with the policy’s definition of a disability. With cases involving the denial of life insurance and AD&D benefits, insurers may cite a policyholder’s unhealthy habits or a dangerous job as a disqualifying factor.
Missed Deadlines
If you miss a filing deadline for benefits, you may lose out on your employer-provided benefits. This applies to the initial claim as well as the appeal process. For example, you have just 180 days to file and appeal for denied ERISA life insurance benefits. If you miss that deadline to file an appeal, you will lose your ability to seek those benefits even if the insurer was wrong to deny them.
Lack of Medical Evidence
For short-term disability benefits and long-term disability benefits, the insurance company may state that your records do not support the severity of your injury, illness, or diagnosis. You may even lack objective tests to prove your inability to work. There have also been situations in which a doctor’s notes or diagnoses are considered vague.
Disagreement with the Diagnosis
Insurance companies have physicians on staff whose job is to dispute your doctor’s diagnosis. Even if the insurance company’s physician has never examined you (let alone met you), they can still disagree with your doctor’s opinion and deny your claim.
Pre-Existing Conditions
An insurer may claim that your condition is linked to a pre-existing condition rather than a new illness or injury. They will often consider the full scope of your medical history in order to dispute your eligibility and deny coverage.
Plan Limitations and Exclusions
Many insurance policies include limitations on coverage and exclusions from coverage. Unfortunately, these limitations and exclusions are often hidden in the fine print, and policyholders are not aware they exist until they are denied the benefits they thought they’d earned.
Errors in Paperwork
Any mistakes in paperwork, missing documents, or gaps in your medical history could be used as grounds to deny your claim. Even if you’re usually careful and detail-oriented, just one minor error is all it takes to be hit with a denial letter.
Insurer Surveillance
Insurance companies will keep tabs on you after claiming disability. Any photos or videos on social media that suggest you are physically capable can be used to deny or cut off your benefits. Some insurers may even have a detective spy on you while you’re around your home or neighborhood, looking for any evidence that you are able-bodied rather than recovering from a major injury.
If My ERISA Claim Is Denied, Can I File a Bad Faith Lawsuit?
No. You cannot file a bad faith insurance lawsuit if your employer-provided plan is subject to ERISA regulations.
ERISA is a federal law that preempts state bad faith laws. You have an entirely difficult route to seek denied benefits, and it’s a much more complicated and frustrating process.
Your ERISA Appeal Is Crucial: You Need a Lawyer ASAP
You have a short amount of time to file an appeal for a denied ERISA claim. While some benefits have a 180-day deadline, you may have just 60 days to file an appeal for denied pension or retirement benefits. The denial letter will state how much time you have to appeal.
No matter the deadline, don’t delay. It’s best to speak with an Alabama ERISA lawyer as soon as possible.
For a free consultation with experienced ERISA lawyer Tom Sinclair, contact our Birmingham law office today. We’re ready to help you out.
Why You Need an ERISA Attorney for the Appeal Process
The odds are stacked against you in ERISA cases. This is because insurance companies have learned how to game the language of the law and turn it against regular, hard-working people just like you.
There are many reasons why you need an ERISA lawyer. Here are just a few reasons you should hire an attorney when ERISA benefits get denied:
- An ERISA Lawyer Can Explain What You’re Up Against: Most people don’t hear about ERISA or read the word until their claim is denied. An attorney can explain everything you need to know about ERISA and the appeal process in a language you can understand.
- An ERISA Attorney Can Ensure You Hit Those Key Deadlines: There are tight windows to start the administrative process, and you need to abide by them. Your ERISA lawyer can make sure your appeal is fully prepared and properly filed so you can seek those benefits you were wrongfully denied.
- An ERISA Lawyer Knows How to Structure an Appeal: Your ERISA appeal is the legal foundation of your entire case. No new evidence can be presented if you need to go to trial. Your ERISA attorney will know what evidence to include with your appeal and what additional material to have to persuade a judge should your case go to federal court.
- An ERISA Attorney Can Provide Realistic Expectations: ERISA appeals and trials can be difficult and frustrating. Your lawyer can keep you updated as your case progresses while also giving you a good understanding of what to expect as you fight for those benefits.
How an ERISA Lawyer Can Help You with Your Appeal
We mentioned that a lawyer can help you understand the ERISA appeal process. Here’s a basic rundown of what happens during an appeal.
The ERISA appeal is an internal administrative process, with a representative at the same insurance company that denied your benefits reviewing your appeal materials. You must exhaust administrative remedies during this appeal process before you can go to trial.
Your lawyer will build the strongest case possible with your appeal. Attorney Tom Sinclair treats the appeal as your legal foundation. He crafts ERISA appeals carefully and includes supporting medical documentation, vocational assessments, personal statements from family, friends, and co-workers, and much more.
The above is all done while adhering to those strict administrative deadlines.
What If My Appeal Is Denied and I Need to Go to Trial?
Say that you’ve exhausted your administrative remedies and your appeal is unsuccessful. You can now bring your ERISA case to federal court. However, this won’t be a trial with arguments, added evidence, or a jury of your peers. With ERISA cases, a federal judge can only review your appeal materials and make a decision based on that.
This is why Sinclair Law Firm treats that appeal as your legal foundation. All of the evidence presented will help convince a judge that your benefits should have been granted.
There is a difficult legal standard that must be met for a judge to rule in your favor. You can increase your chances of successfully securing your benefits by working with an experienced ERISA attorney who understands the process and how to craft a strong appeal.
Why You Need Sinclair Law Firm for Your ERISA Case
You’ve read about the challenges of ERISA appeals and trials. You’ve read about the tight deadlines and difficult legal standards when claims go before a federal judge. We’ve also mentioned how Sinclair Law Firm approaches these challenges, and how we do right by clients who are simply trying to recover or retire with dignity.
You can’t afford to go it alone with ERISA denials and appeals. Alabama attorney Tom Sinclair and his team are ready to help out in whatever way we can.
Our Firm Knows How Insurers Think and Operate
When Tom started his legal career, he represented the auto and insurance industry. He had a change of heart and found his true calling involved helping people let down by this system. Tom knows the tactics insurers use to deny claims and pressure normal people. He also knows how to push back and level the playing field.
Insurers Know Our Firm and Its Reputation by Name
When case files come up with Tom’s name in them, insurance companies will flag those files. That’s a feather in our cap. It means that insurance companies know our reputation for fighting hard and really advocating for our clients. When you work with Sinclair Law Firm, insurance companies know what they’re up against.
We Represent Alabamians from All Walks of Life
Our team isn’t concerned about your politics or how much you make every year. When the system lets Alabamians down, we’re here to right that wrong as best as we can. We’re here for everyone in Birmingham and other parts of the state who need help getting their benefits. Tom and his team are here for you.
Our Firm Offers Free Claim Reviews
Sinclair Law Firm will review your case, your claim, and your insurance policy for free. We only represent clients when we know we can do good for them. With a free, no-obligation consultation, you can find out if your ERISA case is viable and what steps to take next.
We Can Find a Payment Arrangement That Works for You
You were no doubt counting on those benefits. Times may be tighter than usual because of your denied claim. Our team will accommodate your financial situation and find a fair payment arrangement that works for you. You deserve legal help, and we want Alabamians to know they can count on us regardless of their income.
Request a Free Claim Review at Our Birmingham Law Office
No matter why your ERISA insurance benefits were denied, you can file an appeal and possibly get your case reviewed in court. Don’t go through this process without a skilled attorney on your side. Tom Sinclair and his team are prepared to help you in whatever way we can.
The clock is ticking, and we’re ready to help. To request a free case evaluation with an experienced Alabama ERISA lawyer, contact our Birmingham law office today. You can also get in touch with Sinclair Law Firm by calling (877) 249-0091.