Most people encounter the word “ERISA” for the first time when their employer-sponsored benefits have been denied. These kinds of claims can be complicated and frustrating, and if you aren’t careful, you may lose your ability to obtain the benefits you were wrongfully denied. This is why it’s so important to speak with an ERISA lawyer in Alabama as soon as you receive a denial letter.
At Sinclair Law Firm, we’ve assisted many Alabamians with the ERISA appeal process. It’s something our team feels passionate about, and we’ve built a strong reputation for helping people who’ve been let down by the system.
Let’s review the ERISA claim process, what happens during an ERISA appeal, and what to expect if your ERISA appeal needs to be reviewed by a federal judge. For a free consultation with an experienced ERISA claim attorney near you, contact our Birmingham law firm today. You can also call us at (877) 249-0091.
What Is ERISA?
The Employee Retirement Income Security Act (ERISA) is a federal law that was passed in 1974. It was originally intended to protect employee pensions, though its scope expanded before it was signed into law. Most employer-sponsored plans are subject to ERISA regulations, including disability, life insurance, and retirement plans.
Despite the best intentions of lawmakers, ERISA has become a useful tool for insurance companies when they deny a claim. The federal law supersedes state laws regarding employer-sponsored benefits, which means there’s a totally different appeal and litigation process for ERISA claims.
How Do I Know If My Plan Is Governed by ERISA?
For most people, benefits are governed by ERISA if these benefits are part of an employer-sponsored plan. There are some exceptions that we will note below.
The best way to find out if your policy is subject to ERISA regulations is to speak with your employer or your plan administrator. They can give you a direct answer about your policy.
What Plans Are NOT Governed by ERISA?
Not all employee benefits are subject to ERISA regulations. Certain types of benefits and types of employers may be exempt. Plans that are not governed by ERISA include:
- Unemployment
- Workers’ compensation benefits
- Social Security Disability benefits
- Government employee plans
- Church/religious employee plans
- Plans of Indian tribal governments
- Insurance plans outside of the United States
- Unfunded excess benefit plans
Again, if you are not sure if your plan is governed by ERISA, be sure to check with your employer or plan advisor.
What to Submit with an ERISA Claim
When seeking benefits from an employer-sponsored plan, be sure to include the following documents:
- A Formal Claim Letter: In your written claim letter, be sure to include your name, contact information, the name of the plan, whether you’re an employee or beneficiary, a description of the benefit you’re claiming, and any relevant dates or context.
- Completed Claim Forms: Make sure your completed claim form is submitted. Depending on what benefits you’re seeking, you may also be asked to provide a statement from your employer and/or a statement from a doctor.
- Any Supporting Documentation: The types of supporting documents you submit will depend on the benefits you’re trying to claim. This might include medical records and hospital bills, beneficiary designation forms, or a marriage certificate.
- Proof of Eligibility: You may be asked to provide supporting evidence that you are covered under the plan, including proof of employment or dependent status.
- Prior Correspondence with the Insurer: If there is any relevant correspondence with your insurer that is pertinent to your benefits, be sure to include this correspondence with the documents you submit.
- Any Additional Required Documents: Check if you need to obtain and submit any other forms with your ERISA claim. Being thorough at the outset can help avoid delays or denials.
Before you submit your claim, be sure to make a copy of everything you provided for your own records. Send your claim through certified mail or any trackable method to ensure your materials are confirmed received.
What Happens If My ERISA Claim Is Denied?
If you receive an ERISA denial letter, read through it carefully. The denial letter will tell you why your claim was denied and note any relevant provisions in your plan. This denial letter will also outline the ERISA appeals process and what deadlines you need to meet when filing an appeal.
As soon as you receive that denial letter, the clock starts ticking on your ERISA claim. It’s best to contact our Birmingham law office as soon as possible to speak with a lawyer about what steps to take next. Sinclair Law Firm can provide you with all the support you need during a complicated and confusing process.
Why ERISA Appeals Are Complicated and Frustrating
We mentioned earlier that ERISA claims have a completely separate appeals and litigation process from non-ERISA claims. Here are some specific challenges people face if their ERISA claim gets denied.
You Have a Limited Time to File an Appeal
There is a narrow window to submit an ERISA appeal. This deadline will be mentioned in your denial letter. For most life and disability benefits, there’s usually a 180-day deadline. For pensions and retirement benefits, that deadline can be as short as 60 days.
Once that deadline to file an appeal expires, you may not be able to seek those benefits in court. It does not matter if the insurer was in the wrong when they denied your claim. Once that deadline is up, your benefits may be gone.
You Cannot File an Insurance Bad Faith Claim
For non-ERISA plans, you may be able to file a bad faith insurance claim to seek your denied benefits as well as legal damages. With ERISA claims, bad faith litigation is not an option.
For ERISA plans, you need to file that appeal and exhaust your administrative options. If your appeal is denied after an independent internal review, your appeal is then reviewed by a federal judge instead of a jury of your peers.
In addition, if the judge rules in your favor and you win, you are only entitled to the benefits you were denied. You cannot seek any additional damages as you would in an insurance bad faith claim.
There Is a Difficult Legal Standard Before a Federal Judge
The ERISA case before a federal judge is not like other hearings.
First, new evidence is rarely admitted in an ERISA case. The federal judge usually just reviews your appeal and administrative record and then makes a decision based on what was submitted. If your appeal does not lay a strong legal foundation, the denial will stand.
Second, your appeal must demonstrate that the insurer’s decision to deny your claim was unreasonable or capricious. This abuse of discretion standard is a high bar to meet, and a judge may have to let the denial stand if the documents in your appeal cannot demonstrate an abuse of discretion. In other words, you may have a point, but it does not show that the insurer was capricious and arbitrary in rendering their decision.
What Happens During an ERISA Appeal?
During the ERISA appeal process, claimants will submit a formal written appeal. This appeal should include a request to appeal the denial, an argument why the denial was incorrect, any supporting evidence to back up your claim, and any documents requested by the insurer.
If your appeal is submitted within the specified deadline, it will then be reviewed independently. The person who reviews your appeal will not be the same person who initially denied your claim.
The insurer will then issue a final decision, though it can take time for this decision to be made. For most disability claims, final decisions must be issued within 45 days, though there is a 45-day extension for a total of 90 days. For pensions, final decisions must be issued within 60 days, though there is a 60-day extension for a total of 120 days.
What If My Appeal Is Denied?
If your appeal is denied, you can then seek your benefits in federal court. Again, this is not an insurance bad faith claim, and the federal judge can only review the evidence that was included in your administrative record.
When a federal judge reviews your ERISA claim file, the judge will need to consider whether the documents demonstrate that the insurer was unreasonable in its initial claim denial.
It can take months for ERISA litigation to be resolved, and even longer if a case is particularly complicated.
Do I Need an Attorney During an ERISA Appeal?
Yes, most definitely.
There are many compelling reasons why you need an ERISA lawyer. An attorney can keep you on task and ensure deadlines are met. Your lawyer can also explain what is happening so you do not feel confused or overwhelmed by the process.
Preparing Your Appeal with Litigation in Mind
Your appeal is your one shot at proving your case. Since new evidence will likely not be permitted in a federal hearing, you need to get all supporting documents and records into your appeal. Further, your written appeal needs to be compelling, meticulous, and written with the abuse of discretion standard in mind.
By working with an experienced ERISA appeal attorney like Tom Sinclair, you can help ensure your best chance of securing your benefits. We determine what additional tests, evidence, and documents to include in your appeal so it is ready to stand up to a federal judge’s scrutiny.
There Is a Low Rate of Success in Alabama Federal Court
We looked at 360 ERISA claims filed during a five-year period. Only 4 of the filed claims were in favor of the plaintiff/insured employee. That’s just a 1% success rate if your ERISA claim needs to go all the way to federal court.
During the ERISA appeal process, Sinclair Law Firm will treat your appeal as a legal foundation. We’ll build an appeal with strong supporting documentation and gear all materials to help demonstrate abuse of discretion on the part of the insurer.
Why Choose Sinclair Law Firm for Help on ERISA Claims
The ERISA claims process is tough, but our team can break it down into language you can understand and provide guidance every step of the way. Here are some of the big reasons why Alabamians contact our law office in Birmingham for assistance with ERISA.
- We Know How Insurers Operate: Tom began his legal career working for insurance companies and automakers. He realized his true calling was helping people who are mistreated by this system. Our team can use this understanding of insurance company tactics to build strong ERISA appeals.
- Insurance Companies Know Our Reputation: Some insurance companies flag files when they see Tom’s name in them. This speaks to our reputation as strong advocates for working people against insurers.
- We Have Access to Trusted Experts: Insurers have their own experts who justify the denial of your ERISA benefits. Sinclair Law Firm also has a team of experts who are ready to vouch for you. We’ll help you meet with specialists who can build a truthful and compelling case as part of your appeal.
- We Offer Free Claim Reviews: We offer free claim reviews so you can speak with a professional about ERISA without any fees or sense of obligation. We’re here to help you when the system feels confusing, overwhelming, or stacked against you.
- We Can Work Out Fair Payment Arrangements: Finances may be tight if you’re counting on benefits that have been denied. During your free consultation, Sinclair Law Firm can work out a fair payment arrangement based on your finances.
As soon as you receive that denial letter, you need us on your side. Do not hesitate to contact our Birmingham, AL law firm to discuss your situation.
Contact Attorney Tom Sinclair for Help with the ERISA Process
If you’re confused or anxious about ERISA, you are not alone. Our team can guide you through a complicated process and help you get the benefits you’re owed. These kinds of cases can be frustrating, but we’re here to provide peace of mind and help ensure you have a strong foundation during an appeal.
For a free claim review with a proven ERISA attorney near you, contact our Birmingham law firm today. You can also reach Tom and his team by phone at (877) 249-0091.