What Happens If My Employee Benefit Claim Was Denied?

At McKennon Law Group, our attorneys work alongside beneficiaries with unions or employer-supplied life insurance policies that involve issues laid out in ERISA, Employee Retirement Income Security Act.

If your appeal is denied, our attorneys are among the best in the nation for bringing a legal action to recover your benefits and enforce your rights. Read on to learn more about ERISA, ERISA claims, and what actions you can take to get the money you deserve.

What is ERISA?

Most of the life, health and disability policies issued through employers in the United States are governed by the Employee Retirement Income Security Act of 1974. The Employee Retirement Income Security Act (ERISA) is defined as “a federal statute which delineates minimum standards for the administration of private industry’s pension plans and establishes the impact that federal income taxes will have on transactions associated with management of such pension plans.”

Additionally, this act also creates causes of action for employee plan participants and their beneficiaries. Under ERISA, employers have financial responsibilities, and employee plan participants can sue the employers in cases of breach of these responsibilities. ERISA provides equity as the remedy for breach of fiduciary duty.

Why Do I Need A Lawyer To Deny ERISA Claims?

If your ERISA claim was denied, you should consider consulting with an insurance litigation attorney and appealing the decision immediately. At McKennon Law Group, we have extensive experience dealing with denied ERISA claims. We have a high success rate of recovering insurance money for those who are entitled to it. We always make sure that, every step of the way, you feel confident and understand the process, and feel assured that your case is always handled professionally.

Our team of attorneys at McKennon Law Group can help those in need with claim denials for many different reasons:

• Claims denied because of changed marital status
• Claims denied because of exclusions
• Claims denied because of a employer’s oversight or mistake
• And much more.

Our Newport Beach ERISA attorneys can offer sound legal advice in every stage of your ERISA claim. We will take the time to explain to you in detail how ERISA works. We’ll let you know all the ways in which you can protect your rights to life insurance beneficiary money, as well. ERISA involves mandatory administrative appeals and strict deadlines, so it is imperative that you know your rights and swiftly hire an ERISA attorney.

How Does A Lawyer Help Me With A Denied ERISA Claim?

If your appeal is denied, you can bring a legal action to recover your benefits and enforce your rights. ERISA claims are the most frequently litigated cases in federal court, and our lawyers have decades of experience helping with these claims.

For those who have yet to file an ERISA claim, we can provide guidance and assist with the claim filing process. It’s best to begin the process of filing a claim with the oversight of an attorney so you can be sure to not miss out on any important steps or supplying any important information necessary.

If your ERISA claim is denied, we can help you understand the contents of the denial letter so you can understand why the claim did not process. If the claim was denied wrongfully, and we believe the insurer has been acting in bad faith, we can help you file an appeal.

For those who are experiencing delays in receiving their ERISA claim, our team of attorneys can work to speed up the approval and payout process as best we can, by serving as a point of contact between you and the insurer. Our goal is to make the expediting process as smooth and effective as possible, so we handle all of the legwork on your behalf.

In representing clients with ERISA lawsuits, we demonstrate before a judge, if necessary, that the employer has breached their financial responsibility that is laid out under ERISA, or that the insurance company has breached their responsibility. If your beneficiary designation was challenged in any way by another claimant, we can stand by your side and defend your right to that money as well.

Call McKennon Law Group Today For A Free Consultation Regarding Your ERISA Claim

We understand how frustrating it can be to fight back against a denied or delayed claim. Our attorneys have been litigating ERISA insurance, disability insurance, life insurance, accidental death and dismemberment insurance, health insurance, bad faith and other insurance matters since 1986. We are nationally recognized in insurance litigation and have led numerous seminars and written many articles dealing with insurance claim issues.

Call our team of attorneys today for a free, no-obligation consultation regarding your ERISA claim.

The long-term disability coverage that your employer has been providing may not be there when you need it. That is why, even before you file your disability claim, you should seek the advice of a California ERISA disability claims attorney.

The Employee Retirement Income Security Act – also known as ERISA – was enacted by Congress in 1974 to make sure that the insurance benefits provided by private employers will be there when employees need those benefits.

ERISA sets minimum legal requirements for the group insurance plans provided through many employers in the private sector. However, long-term disability claims under ERISA are routinely denied by insurance companies. If you need disability benefits that have been denied, you may also need seek the services of a top-rated legal expert for disability insurance cases in San Diego.

What Does a Long-Term Disability Policy Cover?

Long-term disability insurance typically provide benefits if you are unable to perform the important duties of your own occupation due to an injury or sickness. Most disability policies cover a variety of serious illnesses and medical conditions, whether they are classified as physical medical conditions or mental-nervous conditions. On-the-job injuries may be covered, but about 95 percent of the long-term disability claims filed under ERISA are not work-related.

Cancer, mental illness such as depression or anxiety conditions, chronic illnesses, neurological disorders, and certain degenerative diseases may also be covered by your ERISA disability policy.

What Does ERISA Require?

ERISA does not require private employers to provide employee benefit plans. The federal law simply establishes minimum standards for insurance plans that employers choose voluntarily to offer.

When an insurance company or an employer takes advantage of ERISA to reject a disability claim and unfairly deny disability benefits, a California ERISA claims lawyer may be able to appeal the denial of that claim and recover the benefits, or if that appeal is denied, file a lawsuit in federal court to recover these denied disability insurance benefits.

Why are disability claims under ERISA so frequently denied? Are there ways to avoid the most common reasons for denials? How can a denial be appealed, what are your rights if your claim is denied, and what steps will you have to take? These questions will be answered below.

Avoid These Mistakes If You File an ERISA Disability Benefits Claim

If you consult an ERISA claims attorney before you file your ERISA disability benefits claim, your attorney can assist you to avoid these common mistakes, and it is even possible that your claim may be approved:

1.  When a doctor determines that you are disabled, do not assume that you will qualify for disability benefits. Insurers frequently deny disability claims even those that are supported by one or more of the insured’s doctors. Have your doctors write up a comprehensive evaluation of your condition and your disability that discusses your medical conditions and how these conditions affect your ability to conduct everyday activities and your job duties.
2.  Provide a comprehensive statement from you and others that discuss in detail why you are disabled. The statement must include the following information: 1) a detailed description of the duties of your occupation as you performed them; 2) a detailed discussion of the history of your condition; 3) a detailed discussion of your symptoms; 4) an explanation for how those symptoms negatively impact your ability to return to work such that you cannot work; 5) how your disability also impacts your overall quality of life; and 6) a discussion of the things you could previously do but can no longer do.
3.  Adhere to your doctor’s recommendations and do not participate in any physical activities against those recommendations. Do not post anything about your claim online or give the insurer anything that could be used to justify the denial of your disability claim.
4.  The easiest mistake to avoid when you make a claim for ERISA benefits is not working with an ERISA claims lawyer from the start. You must have sound advice because ERISA is a complicated law with many exemptions, terms, conditions, and deadlines.

Will Your ERISA Disability Claim Be Denied?

An ERISA disability claim could be denied for almost any reason – if you make a mistake in the paperwork, for example, or if you miss something in your policy’s fine print. Here are the most common reasons offered by disability insurance providers for denying ERISA disability claims:

1.  inadequate medical documentation of a disability
2. a pre-existing condition
3. missing details, paperwork mistakes, and overlooked deadlines
4. policy exclusions
5. self-reported, undocumented symptoms or unauthorized or inappropriate treatment
6. evidence compiled through social media or private investigation contradicting your claim

When you’ve paid an insurance company premiums for years, and when a doctor has determined that you are disabled, receiving a letter from your insurance company that denies your disability claim can be devastating.

Too often, legitimate disability claims are denied because some insurance companies look for every possible technicality that will allow them to reject a claim. However, an experienced ERISA disability claims attorney may be able to help you if your claim is rejected.

What Are the Rules for ERISA Disability Claims?

Before 2018, you could sue an ERISA insurance provider for the denial of disability benefits only if you and your lawyer could prove the denial was “arbitrary and capricious.” But since 2018, ERISA insurers must provide a “reasoned explanation” when a disability claim is denied.

An insurance company must clearly explain why it disagrees when one or more doctors have concluded that you’re disabled. The company must also identify which of its procedures and policies authorize and support its denial of your claim.

One rule governing disability claims was not changed in 2018. You may not sue an ERISA disability insurance provider until one or more “administrative” appeals of the denial have been filed and considered by that insurance provider.

When Should You Speak to an ERISA Attorney?

When you file a long-term disability claim under ERISA, your best option is having the guidance and advice of a California ERISA claims attorney from the start – even before you begin to fill out the insurance company’s paperwork.

But if your disability claim under ERISA is denied, and if you are not already working with a lawyer, speak with a claims lawyer at once about filing an appeal. A claims lawyer can handle your appeal and ensure that you’ve complied with ERISA’s numerous guidelines.

Because ERISA is a federal law, U.S. District Courts hear ERISA-related lawsuits. If the insurance company rejects your administrative appeal, your attorney may recommend bringing a lawsuit in a U.S. District Court, where a District Judge will decide the case.

What Else Will You Need to Know?

You will need personalized guidance and advice if you apply for disability benefits under ERISA or if your claim is rejected. Your lawyer should have considerable experience representing disabled clients and appealing the denial of their ERISA disability claims.

ERISA does not apply to public-sector employees or to the employees of religious organizations. It also does not cover privately-purchased, individual insurance policies or any benefit or program that is not provided by a private-sector employer.

Most California attorneys who handle ERISA claims provide an initial legal consultation to prospective clients without any obligation or cost. That consultation is your chance to obtain personalized legal advice and to find out more about your rights and legal options.

If you’re disabled, and if you intend to claim disability benefits under ERISA, or if your claim has already been denied, there’s no reason to wait. Do what it takes to obtain the disability benefits you have paid for and need, and contact a California ERISA claims lawyer at once.

In this several-part blog series titled The Basics of an ERISA Life, Health and Disability Insurance Claim, we discuss the basics of an ERISA life, health, accidental death & dismemberment and disability claim, from navigating a claim to handling a claim denial, through the subsequent appeal and litigation.  In Part Seventeen of this series, we discuss when ERISA applies.  ERISA governs a wide variety of employee benefits.  It is safe to say that most employee benefits are controlled by ERISA.  As such, if the employee benefit plan is provided through a private employer, it is likely, but not necessarily certainly, governed by ERISA.  However, at times, instead of ERISA, state law or a governmental organization’s own unique laws and procedures apply.  If a claimant wins their case, ERISA provides for an award of the denied benefits, attorneys’ fees, interest and costs.  State law varies from state to state but may provide for the award of the denied benefits, consequential damages, punitive damages, attorneys’ fees, litigation costs and interest, among other potential remedies.  In other words, if state law applies to an employee benefit claim, greater remedies are available to the claimant. The trial procedures for these two types of claims are very different.  ERISA claims are decided by a judge, typically based on the administrative record consisting mainly of documents submitted to the claims administrator during the administrative appeals process.  Discovery is much more limited.  However, for state law claims, the usual litigation procedures are available.  These include a full panoply of discovery, use of experts and a jury trial.  The procedures for disputing claims for benefits from different governmental agencies vary greatly with each organization often being quite different.  Some claims benefit from being governed by ERISA.  Other claims benefit from being governed by state law.  Given these drastic differences, it is critical to determine which body of law and procedures apply to a claim.

The first broad exception to ERISA’s applicability is that it does not apply to benefits provided by government employers.  See 29 U.S.C. § 1003(b)(1).  This exception applies to benefits provided by municipal, state and federal governments and thus affects the benefits earned by a wide variety of people.  People who work for these different governmental entities may have very different benefits and rights thereto if a claim for benefits is denied.  If a claim is denied, some governmental entities may have a simple appeal process resembling ERISA.  Others may provide for an entire trial and discovery process.  However, this exception may not apply to all government employees.  It depends on how one obtains the benefits.  For example, if the benefits in question were actually obtained through a union, ERISA may control because the benefits were not provided by the government entity, but rather, they were provided by an employee organization: the union.  One has to look at the plan documents and who provides the benefits to determine which area of law applies.

A second major exception to ERISA’s applicability is that it does not govern church plans unless the religious entity specifically elects to be governed by ERISA.  See 29 U.S.C. § 1003(b)(2).  Religious organizations have the right to either be governed by state law or opt into being governed by ERISA.  Religious organizations, such as churches and their affiliated hospitals or schools, provide a wide variety of benefits to their employees.  Given that religious organizations have the right to opt into ERISA, it is often difficult to determine whether ERISA applies.  Once again, checking the relevant plan documents is often the only way to be certain.

A third common exception to ERISA is for plans that are “maintained solely for the purpose of complying with applicable workmen’s compensation laws or unemployment compensation or disability insurance laws[.]”  29 U.S.C. § (b)(3).  This exception is relatively simple.  If the plan merely exists to comply with a state’s worker’s compensation laws, then ERISA does not apply.

There are other exceptions to ERISA, but these are the most common ones.  In light of the differences between ERISA and state law, many people mistakenly assume that one is better than the other.  Even many attorneys make this mistake.  Most attorneys make this error because they are more comfortable with one form of litigation than the other.  Assuming that one form of litigation is superior is simply incorrect.  It depends on the specific details of the claim.  For example, for relatively small claims, ERISA is often much more favorable to the claimant.  Under ERISA, if a claimant establishes that they are entitled to the benefits in question, it is fairly easy to win an award of reasonable attorneys’ fees.  However, under the law of most states, whereas attorneys’ fees and a variety of other damages are available upon successfully establishing bad faith, establishing bad faith may be difficult.  Furthermore, it is often difficult to obtain large amounts of damages beyond the contract benefits if the initial amount in dispute is small.  As a general rule, a claimant seeking a smaller benefit will fare better if their claim is governed by ERISA, with its limited discovery and simplified procedures.

If, however, there is a significant amount of money in dispute, having the matter be governed by state law may be useful.  This is especially true if the party denying the claim behaved in a particularly egregious manner, which may allow an insured to collect punitive damages.  This makes the matter prime for a very large award if the case is won at trial.  These factors will also influence any settlement negotiations and result in a potentially larger settlement.

Given the differences between the various forms of litigation related to employee benefits, it is important to confer with an expert in this area of the law.  Consulting with knowledgeable attorneys, such as those at the McKennon Law Group PC, is critical if you want to receive all of the benefits that you are entitled to under the applicable law.