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ERISA Claims

What is ERISA?

ERISA is short for the Employee Retirement Income Security Act of 1974. It is a federal statute that significantly impacts your rights to recover insurance benefits (e.g. short-term disability, long-term disability, and life and accident) that were wrongfully denied. ERISA impacts your rights during the claims and appeals process, as well as your rights in any lawsuit to recover unpaid insurance benefits. Fortunately, ERISA is limited to group insurance obtained through your private employer. It does not affect individual insurance policies which remain subject to more favorable state laws.

To say ERISA is complicated is an understatement. For example, the Department of Labor has issued detailed claim regulations which direct how an ERISA insurance policy processes insurance claims and appeals. These regulations have specific deadlines that apply to you, and that apply to the insurance company. In particular, the ERISA claim regulations contain specific deadlines for you to submit your claim and to submit your appeal. If you miss one of these deadlines, you may lose the right to receive the insurance benefits and lose the right to pursue a lawsuit to recover unpaid insurance benefits.

In a lawsuit, the federal court (not state) will decide your insurance claim. There will not be a jury and you will not be permitted to offer any new evidence or proof. The judge will only consider what is contained in the insurance company’s claim file (called an administrative record). This means it is crucial for you to provide the insurance company with all of your during the claims and appeals process.

Don’t delay – time is of the essence when filing an ERISA claim, appeal or lawsuit.

Feeling frustrated and uncertain in dealing with an ERISA insurance claim is normal. The insurance policies are confusing and hard to read. The insurance company claim representatives are not much help and often make things more confusing and frustrating. This is no accident.

Insurance companies do not make money paying ERISA insurance claims. That is why they put hurdle after hurdle in your way, from requesting more and more information to simply delaying a decision. With each hurdle, the insurance company is counting on you giving up or missing a key deadline. Either way, the insurance company avoids paying your ERISA insurance claim. The stress and uncertainty that comes with this process can be daunting. It doesn’t have to be that way.

Let an experienced attorney guide you through the ERISA insurance claim maze.

You should have access to the most experienced legal representation when fighting an ERISA insurance claim. We provide you with an initial free consultation with our experienced staff. Our goal is to eliminate your stress and anxiety while working to obtain a positive outcome. We strive to provide each client with personalized and reassuring guidance. At Grabhorn Law, while the law is our profession, people are our motivation.

Filing a Claim

Time is of the essence – Do not delay filing your ERISA insurance claim. Here are some helpful tips.

Review the Insurance Policy. Make sure you have get a copy of the ERISA insurance policy and plan documents (ask for them in writing and read them). If you have questions about the policy or plan terms, ask the insurance company. Again, ask in writing.

Cooperate with the insurance company. Complete their forms. Do what they ask you to do.

Do everything in writing. If you can’t, then make sure to keep a log of who you talked to, (date, time, phone number), and what you discussed.

Ask questions about other benefits. Ask the insurance company if you are eligible for any other insurance benefits, such as pension, disability or life insurance. If so, ask what you need to do to file a claim for those benefits.

Ask what else is needed for your claim to be approved. Do this in writing and repeat it in every letter you send to the insurance company.

Filing an Appeal

Time is of the essence – Do not delay filing your ERISA insurance appeal. Here are some helpful tips.

File Your Appeal. Generally, you only have 180 days in which to file. If you fail to file an appeal, you may lose your right to your benefits.

Ask for a complete copy of your claim file, including a copy of the insurance policy and plan documents. Make sure to review these completely and correct any errors when you file your appeal.

Prepare your evidence. Get a copy of your medical records from your doctors. Make sure your doctors have noted your limitations and restrictions that prevent you from working, including any side effects from your medication. If possible, have the doctor or medical examiner review the claim denial letter and comment on why they disagree.

File your appeal in writing and provide additional evidence supporting your claim. Even if you only submit a one-page note stating your appeal, make sure you file the appeal.

Ask the insurance company what else is needed for your appeal to be granted. Do this in writing and repeat it in every letter you send to the insurance company.

Filing a Lawsuit

Time is of the essence – Do not delay filing your ERISA insurance lawsuit. Here are some helpful tips.

Do not delay. There are strict deadlines for filing a ERISA lawsuit. The insurance policy and plan documents may limit this time period, as well as state law. Time is not your friend.

Do not be afraid of filing a lawsuit. It’s your legal right. Yes, it may take time, but it’s the only way to obtain the ERISA insurance benefits you are owed. If you use an attorney, you can be involved as much or as little as you like. Your attorney should make the process as smooth and stress-free as possible.

Look for an experienced law firm. Not every law firm has experience with ERISA insurance claims. Make sure the law firm you choose has experience in dealing with not just your ERISA claim, but also with your medical condition and your insurance company.

Look for a law firm willing to try your case. Although the majority of ERISA lawsuits resolve prior to a trial or judgment, if your case does not, you need to make sure you have a law firm experienced in successfully pursuing an ERISA lawsuit to a final decision.

Location should not matter. You should not limit your choice of an attorney based on whether they are located near you. The most important factor should be experience, followed by your comfort level. With today’s technology, you should have the best of both – experience and comfort.