When you’ve been denied disability benefits, are facing an appeal process after your claim was denied, or are simply confused about your rights under your employer-sponsored plan, you’re probably feeling pretty overwhelmed. Understanding the Employee Retirement Income Security Act, better known as ERISA, and working with an experienced ERISA lawyer are essential to getting what you’re owed. That’s where our very own Tom Sinclair comes in.
Today, Tom is sharing practical, experience-based answers to some of the most pressing questions you may have about employee benefits law. Whether you’re just starting the claims process or preparing for a lawsuit, the insights below could make all the difference.
Keep reading to learn more!
What Makes ERISA So Different from Other Areas of Law?
Employee benefits seem so straightforward, until you’re denied a claim, that is. Then the complex rules of ERISA kick in. Below, Tom breaks down why this law makes handling your own appeal risky.
What is special about the law when it comes to employee benefits, such as group insurance policies and retirement benefits?
While ERISA began as a law to protect workers’ pensions, it was expanded to cover group health, life insurance, and disability policies. The key takeaway is that ERISA dramatically reduces an employee’s rights in a lawsuit.
What does it mean when someone having a claim governed by ERISA has to complete an “administrative process” before filing a lawsuit?
When the plan administrator, which is an insurance company if there is a group policy, denies any kind of benefit governed by ERISA, they will inform the participant that they have a right to pursue an “appeal” of that denial or termination of their claim. This is what ERISA considers to be the “administrative process,” and it is required before you can bring a lawsuit. A court will dismiss any suit over an ERISA-governed benefit if no appeal has been lodged.
Is submitting an appeal as simple as sending in a letter by the deadline that says, “I appeal,” and nothing more?
No, you must shoulder the burden of collecting and presenting all of the evidence in support of your claim.
The claimant must present all evidence to the insurance company before filing a lawsuit, which is their only opportunity to do so. This administrative appeal is critical as the court will only review evidence submitted during this phase and will not consider additional evidence later. Therefore, it is advisable for claimants to involve an ERISA attorney immediately after being offered an appeal right, since a strong presentation of evidence is essential for a favorable outcome. Handling the appeal incorrectly can lead to significant challenges in court. Many times, I am unable to take cases where individuals managed their own appeals due to a weak record with the insurer, making their claims hard to win. Thorough preparation of an appeal is crucial.
Understanding the basics of ERISA is only the beginning. What sets ERISA apart is how unforgiving it is if you miss a deadline or procedural requirement. Having a knowledgeable guide like Tom on your side early in the process can be the difference between obtaining the benefits you’ve earned and your claim never standing a chance.
The Appeal Process
Once your claim has been denied, the appeal process is your one and only chance to prove your case. Here’s what you’ll need to succeed:
What does an “appeal” involve when it comes to an employee benefit or insurance claim that has been denied?
It must always be submitted in writing, along with a request that the denial be overturned. Additionally, it must be submitted on time. If that deadline is missed by even a day, the administrator or insurance company is completely free to reject that appeal as late and to consider that claim forever closed. This also means a federal court will refuse to hear your case, so paying attention to the appeal deadline and acting promptly is critically important.
What happens next if the plan administrator or insurance company denies the appeal?
The next step is to file a lawsuit. Where ERISA lawsuits are unusual lies in that there are no punitive damages or jury trials, and no new evidence is allowed.
What are two of the most common problems you see when someone who is not familiar with ERISA’s unusual qualities tries to handle their own appeal?
There are many things that can go wrong when that happens, but the two most common and fatal are:
- Failing to obtain important evidence supporting the claim while handling the administrative appeal on their own. A note from the doctor isn’t going to get the insurance company to reverse their decision or persuade a federal court, either.
- Failing to pay attention to their Plan’s deadlines can make even strong cases impossible to pursue. This is usually because they’re already so overwhelmed with everything else they have going on.
The ERISA appeal isn’t just a step; it’s the “big break” moment for your case. Having an ERISA lawyer there to help you from day one can significantly increase your chances of success.
When Should You Contact an ERISA Lawyer?
Most claimants wait too long to get help from an ERISA lawyer, usually because they’re hoping they can handle things themselves. But waiting can cost you the entire claim.
When should a claimant consider asking an attorney to assist them with a claim for benefits governed by ERISA?
A claimant should contact an attorney immediately after receiving notice of the initial denial or termination of benefits.
If the claimant waits until after they have already tried their hand at an appeal, it may well be too late. At that point, an attorney may not be able to do anything because they will not be able to repair any problems with the quality or persuasiveness of the evidence in the record that the Federal Court will consider.
Getting an attorney involved early greatly increases a claimant’s probability of recovering their benefit. A well-done and thorough appeal package that provides overwhelming proof of each element of a benefits claim often leads to an outright reinstatement of the benefit without the need to file a lawsuit, which is where the claimant’s odds drop considerably.
What is the most common ERISA claim you see in your practice?
Life insurance claims and claims involving the denial or termination of short or long-term disability benefits are the most common.
What is necessary to prove a disability claim under an ERISA plan?
Proving an ERISA disability claim is a three-legged stool consisting of:
- Proof of diagnosis
- Proof of restrictions and limitations
- Proof that the assigned restrictions and limitations prevent the claimant from working as defined by their plan.
If one of these legs is missing, the claim will be denied, and those denials are almost always upheld in court.
How much time do you have to bring one of these claims after you have gone through the policy’s appeal process?
ERISA does not have its own limitations period for bringing a claim. Instead, it defers to different states for their limitation periods for comparable claims. For a claim for benefits under ERISA, that law might be the state law applicable to insurance contracts. Generally speaking, though, the limitations period is almost always set in the Plan or policy itself. It can be as short as 1 year or as long as 6 years. The difficult part is that most claimants will not know this unless they can obtain a copy of their plan or policy. It is always wise, though, to act quickly with all ERISA deadlines, including this one.
Waiting to seek legal help with your ERISA claim is almost always a mistake. Your best bet is to call an experienced ERISA lawyer, like Tom Sinclair, the moment your claim is denied. This is your greatest chance at preserving your rights and strengthening your case.
Get Help from Sinclair Law Firm Before It’s Too Late
Claimants usually don’t realize how high the stakes are in an ERISA case until it’s too late. From short, rigid deadlines to the inability to introduce new evidence in court, the system is made to favor insurance companies—unless you have the strategies to fight back.At Sinclair Law Firm, we have the knowledge, insight, and legal expertise to level the playing field and help you win your case. If you’ve been denied disability benefits or a life insurance claim, act fast and contact us to ensure you have every possible advantage on your side!