ERISA Archives - Page 2 of 55 - McKennon Law Group

How to Choose the Right Lawyer for an ERISA or Insurance Bad Faith Claim

If you have made or are considering making an insurance claim pursuant to the Employee Retirement Income Security Act (ERISA) or a bad faith claim, choosing the right lawyer can make a significant difference in the outcome of your case. ERISA claims and insurance disputes are complex legal matters in which having the right legal representation can be the difference between success and failure for the claim. Here are key factors to consider when selecting a lawyer to handle your ERISA or insurance claim:

1. Experience with ERISA and Insurance Bad Faith Law

ERISA is a complex federal law and ERISA claims have unique procedural requirements, including strict deadlines, and limited evidence rules. For example, if your ERISA claim for disability benefits is denied, you will generally have 180 days to submit an appeal. If you miss the appeal deadline, then file a lawsuit against the insurance company for the benefits, the insurance company will almost certainly move to have the case dismissed for failure to exhaust administrative remedies, and you will likely lose your right to disability benefits. Choose a lawyer with specific experience handling ERISA disability claims, life insurance disputes, pension claims, health insurance claims, and accidental death and dismemberment (AD&D) cases. Verify that the attorney has a track record of successfully navigating ERISA’s administrative appeals process and litigation when necessary.

2. Knowledge of Insurance Company Tactics

Insurance companies often deny claims based on technicalities, policy exclusions, or insufficient evidence. A qualified ERISA and insurance bad faith attorney should be familiar with the strategies insurers use to deny claims and be prepared to counter them. You can gain a significant advantage in your case if your attorney understands how the insurance company and its counsel operate. For example, an attorney with experience defending claims for insurance companies who represents claimants will know how the insurance company will address any number of issues in a case. Such knowledge is a valuable asset. Robert McKennon, the managing attorney at McKennon Law Group PC, had 24 years of prior experience representing insurance companies prior to representing plaintiffs and ERISA plan participants and beneficiaries, and therefore has a deep understanding of how to deal with them.

3. Proven Success in Appeals and Litigation

ERISA requires claimants to exhaust all administrative remedies before pursuing a lawsuit; the appeals process is therefore critical. Look for an attorney who has successfully overturned claim denials at both the administrative and litigation stages. Check for settlements, verdicts, and client testimonials to assess their track record. Published court opinions, a firm’s success stories, and client reviews can provide insight into an attorney’s level of success, particularly with cases similar to yours.

4. Understanding of Medical Evidence and Expert Testimony

ERISA disability claims often hinge on the quality of medical evidence. The right lawyer should have experience working with medical experts, reviewing diagnostic reports, and presenting evidence that clearly demonstrates how the disability affects the claimant’s ability to work. For example, take an accidental death case handled by McKennon Law Group, PC. The claimant’s husband was an alcoholic who essentially needed alcohol to be able to function, so his blood alcohol level was elevated at virtually all times. In the middle of the night he got up to use the restroom then fell and hit his head. He went back to sleep. A few hours later he had a seizure. He never recovered and died in the hospital three days later. The insurance company took the position that his death was excluded from coverage based on a common exclusion found in such policies that says when a person has alcohol or another substance in his system, it is presumed that the alcohol or substance caused or contributed to the death. Because the knowledgeable lawyers at McKennon Law Group PC understood the medical evidence and the law and found a good expert to provide a report concluding that the death was not caused by the alcohol, the widow was successful in her case.

5. Clear Communication and Transparency

A good lawyer should be able to explain your legal options clearly, outline potential challenges, and keep you informed throughout the process. Look for transparency regarding fees, timelines, and case strategies during your initial consultation.

6. Familiarity with Federal Court Procedures

ERISA claims are governed by federal law and are litigated in federal court. Ensure the lawyer you choose is experienced with federal litigation and understands ERISA’s unique legal standards. If you hire a lawyer who is versed only in state law matters, you risk missing a deadline or failing to meet a requirement of the federal court and it could result in the dismissal of your case. Knowledgeable lawyers also know about the judges they appear in front of and this can be a significant help in understanding how a judge will rule.

7. Fee Structure and Costs

Understand how the attorney charges for their services. Many ERISA lawyers work on a contingency fee basis, meaning they only get paid if you win your case. Others may charge hourly or flat fees. Make sure you clarify fee agreements upfront. A prospective attorney should provide you with a draft agreement for you to review, will give you time to review it thoroughly, and will answer any questions you have about it until you have a full understanding of the terms included. Attorneys have many different types of fee agreements and some perform work on an hourly and contingency fee basis to best suit your needs.

8. Reputation and Client Testimonials

Research the attorney’s reputation within the legal community and among past clients. Look for client reviews, peer ratings, and professional recognitions that reflect the attorney’s competence and success in handling ERISA and insurance cases. On the McKennon Law Group PC website, you can find dozens of glowing review from previous clients and you will find a plethora of success stories that discuss the firm’s many successes. On this website, you will also find a biography of our attorneys and their recognitions. For example, look at the experience and professional recognitions for McKennon Law Group’s managing attorney, Robert McKennon. Compare that to any ERISA and employee benefits attorney in the country and you will find that he is at the top of the country’s legal profession.

9. Local Expertise with ERISA Claims

While ERISA is a federal law, some aspects of insurance claims can vary based on the jurisdiction, and even on the judge hearing the case. Choosing a lawyer familiar with your federal district court’s handling of ERISA cases can be advantageous. The lawyers at McKennon Law Group PC have extensive knowledge of the judges who handle ERISA matters around the United States, particularly on the West Coast.

Conclusion

Selecting the right lawyer for an ERISA or insurance bad faith claim requires careful consideration of experience, specialization, and a proven track record of success. By choosing a knowledgeable attorney who understands the intricacies of ERISA law and insurance bad faith disputes, you can ensure maximum success in your case. The lawyers at McKennon Law Group PC have all of the above and then some.

Why Do Disability Insurers Deny Disability Claims and How Do You Successfully Appeal an ERISA Disability Claim Denial

Reasons for Denials of ERISA Disability Claims

Many people make career decisions with employee benefits in mind. Being covered by employer-sponsored health, life, and disability insurance can provide peace of mind that you and your family have a safety net should the worst happen. This is especially the case with disability insurance. Disability insurance protects you if you cannot perform the important duties of your occupation because of an injury or sickness and thus cannot work at your job. What do you do if you cannot work due to medical conditions that prevent you from performing your job duties and your ERISA disability insurer denies your disability claim?

ERISA-related disability claims are often denied for numerous reasons. Here are some of the most important and common reasons for denial:

Insufficient Medical Evidence

Explanation: The claimant fails to provide adequate documentation or medical evidence to support the claim of a disabling condition.
Details:
- Lack of detailed physician reports or diagnostic test results.
- Gaps in medical treatment or inconsistent medical records.
- Opinions from medical professionals that do not align with the claimed disability.

2. Definition of Disability Not Met

Explanation: The claimant does not meet the policy’s definition of disability, which can vary between plans.
Details:
- Some plans distinguish between “own occupation” and “any occupation” definitions of disability.
- Claims are often denied if the insurer determines that the claimant can perform some form of work, even if it is not their previous occupation.

3. Pre-existing Conditions

Explanation: The disability is linked to a pre-existing condition that is excluded under the terms of the policy.
Details:
- Policies often exclude coverage for conditions that existed or were treated during a specified period before coverage began.

4. Failure to Follow Treatment Plans

Explanation: The claimant does not follow prescribed treatment plans or fails to attend required medical evaluations.
Details:
- Insurers may argue that treatment adherence could improve the condition and enable the claimant to work.

5. Lack of Objective Evidence

Explanation: Many policies require objective medical evidence (e.g., imaging or lab results) to substantiate the claim.
Details:
- Claims based solely on subjective symptoms like pain or fatigue may be denied if they lack corroborating objective evidence.

6. Administrative or Procedural Issues

Explanation: Errors or omissions during the claims process can lead to denial.
Details:
- Missing deadlines for filing claims or appeals.
- Failing to provide requested documents or forms.
- Incomplete or inconsistent application details.

7. Surveillance and Social Media Evidence

Explanation: Insurers use surveillance or social media activity to dispute the severity of the claimant’s disability.
Details:
- If the claimant is observed engaging in activities inconsistent with their claimed limitations, the insurer may deny the claim.

8. Independent Medical Evaluations (IMEs)

Explanation: Insurers often require claimants to undergo evaluations by their chosen physicians, who may dispute the claimant’s disability.
Details:
- IME reports that contradict the claimant’s physician’s findings can be used as grounds for denial.

9. Policy Exclusions and Limitations

Explanation: The disability falls under specific exclusions or limitations in the policy.
Details:
- Policies may limit coverage for mental health conditions, substance abuse, or conditions related to self-inflicted injuries are usually limited to 24 months.
- Some policies cap benefits for certain disabilities to a specific duration.

10. Claims of Improvement or Recovery

Explanation: The insurer argues that the claimant’s condition has improved sufficiently to allow a return to work.
Details:
- Often based on periodic reviews of medical records or IMEs.
- The insurer may use minimal improvement to justify denial or termination of benefits.

11. Vocational Assessments

Explanation: Insurers may argue that claimants are capable of alternative work based on vocational assessments.
Details:
- Denial may occur if the insurer identifies jobs the claimant is allegedly qualified for and capable of performing.

12. ERISA-Specific Procedural Safeguards

Explanation: ERISA governs procedural requirements for claims and appeals.
Details:
- Denials may result from claimants not adhering to the administrative processes outlined in ERISA, such as failing to appeal within specified timeframes.

Determine Why Your Claim Was Denied

You must start by understanding why your claim was denied. When waiting for insurance payments to help cover expenses, a denial letter can make you angry, sad, and stressed. Take your time and read the disability denial letter carefully and consider why your disability claim was denied.

If the denial letter does not include a reason or you do not fully understand the reason, consider calling or writing to your disability insurer representative listed in the denial letter. In a professional, straightforward manner, ask for more details about the denial. Do not agree to or sign anything, but document any additional information you learn.

Review Your Rights and Benefits

Once you have detailed information about the insurance company’s reasons for denying your claim, turn to your benefits documents. Start by reviewing your disability insurance policy/plan. Understanding your policy can help you support a better chance at a satisfactory appeals outcome. Pay attention to your rights under your plan, such as how long you have to file an appeal and what resources are available if your claim is denied.

Meet With an Experienced ERISA Disability Attorney

Once you have basic information about your case, consider contacting an experienced ERISA disability attorney. A lawyer with insurance claims and appeals knowledge can provide critical information and guidance through the process. That starts with understanding the regulations that govern ERISA disability insurance claims and making informed decisions about your claim and appeal.

Even if you are unsure as to what you should do or how to handle your next steps, highly experienced attorneys such as McKennon Law Group PC who regularly handle ERISA disability claims can be extremely helpful. They can review your case and tell you whether an appeal is possible and probable. They can also show you how to achieve the best chances for a positive outcome. Understanding the reasons for denial is crucial for claimants, as it allows them to proactively address potential issues and strengthen their claims or appeals under ERISA-governed disability policies. Here are several reasons to contact experienced ERISA disability attorneys (like McKennon Law Group PC) when your disability claim is denied:

1. Expertise in ERISA Regulations

Reason: ERISA is a highly technical federal law with strict rules and procedures. Understanding its requirements can be challenging for non-experts.
Benefit: An experienced attorney knows how ERISA governs disability claims, appeals, and litigation. They can guide you through the process to ensure compliance and avoid procedural missteps.

2. Assistance with Administrative Exhaustion

Reason: Under ERISA, you must exhaust all administrative remedies (appeals within the insurer) before filing a lawsuit.
Benefit: An attorney can help you build a strong administrative appeal, including gathering the necessary evidence and addressing the insurer’s reasons for denial.

3. Navigating Strict Deadlines

Reason: ERISA has rigid timelines for filing claims, appeals, and lawsuits. Missing a deadline can forfeit your right to benefits.
Benefit: An attorney ensures that all documents and appeals are submitted on time, preserving your legal rights.

4. Building a Comprehensive and Winning Appeal of a Denied Disability Claim

Reason: Insurers often deny claims due to insufficient evidence or technical deficiencies in the application.
Benefit: An attorney can help you gather and present the medical, vocational, and other supporting evidence needed to substantiate your disability claim.

5. Challenging Denials Effectively

Reason: Insurers use various strategies to deny claims, such as disputing medical evidence or relying on biased IMEs.
Benefit: An experienced attorney can identify flaws in the insurer’s reasoning, challenge biased IMEs, and present counterarguments that strengthen your case.

6. Addressing ERISA’s Procedural Barriers

Reason: ERISA limits the scope of evidence and judicial review in disability cases, favoring insurers.
Benefit: An attorney understands how to navigate these procedural barriers, ensuring your case is presented in the strongest possible way.

7. Managing Insurance Company Tactics

Reason: Insurers may use surveillance, vocational assessments, or legal technicalities to undermine your claim.
Benefit: An attorney knows how to counter these tactics, ensuring that your rights are protected and your case is not unfairly dismissed.

8. Maximizing Success in the Appeal Process

Reason: The appeal process under ERISA is often your best chance to secure benefits without going to court.
Benefit: An attorney can help craft a compelling appeal that addresses the insurer’s reasons for denial, includes additional evidence, and maximizes your chances of success.

9. Preparing for Litigation

Reason: If the administrative appeal fails, ERISA allows claimants to file a lawsuit in federal court. However, only the evidence presented in the appeal is typically allowed before the judge who will decide your case.
Benefit: An attorney experienced in ERISA litigation can effectively represent you in court, leveraging knowledge of case law and legal strategy to challenge the denial, while making sure that all relevant evidence is presented in the appeal process.

10. Minimizing Stress

Reason: Handling a disability claim or appeal can be overwhelming, especially while dealing with a disabling condition.
Benefit: An attorney manages the legal and administrative aspects of your claim, allowing you to focus on your health and well-being.

Gather Evidence About Your Case

Whether you work with an attorney on your case or decide to proceed with the appeals process on your own, the next step is likely gathering evidence. Relevant evidence includes medical records, letters from medical providers, images and videos, and written statements from family, friends, co-workers or employers, certification letters from medical professionals, etc.

The more evidence you can gather to support your claim, the better. You may not need to include everything you gather in your appeal, and a lawyer can help you understand how to create a compelling narrative with supporting evidence for your case.

File an Appeal On Time

It is essential to file any appeal within the timelines set out by your plan and by ERISA’s claims regulations, which are normally set forth in the denial letter from your insurance company. For example, your denial letter may state that you have up to 180 days from the date you receive the letter to file an appeal. An appeal filed after that date may not be effective, as missing the deadline can result in automatic forfeiture of your appeal rights and also your ability to file a lawsuit.

Avoid rushing through the appeals process, which can lead to errors and missing information. However, it may be a good idea to try to file your appeal a few weeks or at least several days before the deadline at the latest. This gives you some breathing room and helps ensure your appeal arrives promptly.

Address the Reason for Denial

In your appeal, make sure you specifically address the reason(s) the insurance company listed for denying your claim. For example, if your insurance company denied the claim because there is insufficient medical evidence to support your claimed restrictions and limitations, then you must focus your evidence and arguments on this rationale for denial.

Consider Including Personal Statements

One thing to consider including in an appeal is personal statements from persons who have knowledge of important facts concerning your claim. For example, suppose you are appealing a disability claim denial. In that case, you should include statements from persons who know your medical conditions and who know why you cannot perform your job duties. Letters from your doctors providing an expert opinion on your disability or statements from family, co-workers or friends about your disability status are often important to include in your appeal.

Prepare to Take the Matter Further if Necessary

Remember that your appeal may only be one step in the overall process of getting your claim paid. Depending on your case, you may be able to seek remedies beyond the appeals process. An experienced ERISA lawyer can help you understand your options.

If you are struggling with an ERISA-related claim denial and need help with your appeal, we can help. Reach out to the McKennon Law Group PC by calling 949-504-5381.

How a Previous Divorce Can Impact Your Life Insurance Claim

Understanding Divorce’s Impact on Potential Life Insurance Benefits

Typically, when policyholders purchase insurance such as life insurance, disability insurance, or accidental death and dismemberment insurance, they name one or more beneficiaries to receive benefits under the Policy. A beneficiary is the person who receives the policy benefit payout upon a qualifying event. In the case of life insurance, a benefit is paid if the covered insured passes away in a manner that is covered under the policy.

Many married persons make their spouse the sole beneficiary of these types of policies. That can be true even if the couple has children, as the expectation is that a surviving spouse would use the benefit payout to care for the children too.

However, what happens in this situation if the marriage is over through a divorce and the life insurance policy or the accidental death and dismemberment policy names the divorced spouse as the beneficiary at the time of the insured’s death? Our insurance attorneys can help.

No Automatic Beneficiary Change

It is critical to understand that California law and the law in most states do not automatically effect a change upon divorce. That means that a divorce decree does not automatically remove an ex-spouse as a beneficiary on these policies even if the insured would have wanted the removal of the ex-spouse but did not change the beneficiary designation before he passed away.

Typically, if an insured wants a divorce decree to remove his or her spouse as a designated beneficiary, that must be spelled out clearly in the language of the divorce decree/agreement. Couples who are going through a divorce may want to discuss these types of details with their divorce attorneys and with a knowledgeable insurance lawyer. If you have previously gone through a divorce and this type of detail was not included in the decree, you may want to talk to your insurance agent about options for changing beneficiary designations.

Life Insurance Can Be Considered Community Property

Another critical factor that can impact how life insurance policies and payouts work after a divorce is the fact that these types of policies might be considered community property. If you or your spouse purchased the policy during your marriage—and particularly if you paid the premiums for the policy with communal assets—the policy is likely to be considered community property during a divorce.

This can be an important consideration, as it can drastically change the total value you get from the policy. Consider a hypothetical example where a husband purchases a policy on his own life and names his wife as beneficiary. The policy is for $1 million in benefits, and when the couple gets divorced, the cash value in the policy is $100,000.

One potential outcome in the case is that the court decides the policy is community property. It may award ownership of the policy to the husband but require him to give up $50,000 in cash assets to ensure equitable distribution of the current cash value. At that time, the husband could change the beneficiary on the policy, and the ex-wife is potentially out a million dollars later in life.

The Requirement for One Spouse to Maintain a Life Insurance Policy With the Other Spouse as Beneficiary

In some cases, courts may order or the parties may agree that one spouse to carry life insurance in the future for a specific time, for a specific amount, and that another divorcing spouse is named as a sole or partial beneficiary. This might occur when one spouse makes a lot more money and has been the de facto breadwinner in the family. A life insurance policy can help ensure that child support and other dependent needs are covered if the insured spouse passes away.

Updating Your Life Insurance Policies

Divorced spouses likely will want to make changes to your life insurance policy. They should talk with their insurance agent and their divorce attorneys involved before they move ahead with those changes. They will want to ensure that they are making legal, intelligent changes so there is less likelihood that the changes might be called into question later. That is true even if you are only updating your beneficiary designations.

What to Do if You Run Into Problems With a Life Insurance Claim Post Divorce

Many people think of life insurance as a fairly straightforward purchase. You buy the coverage, and if you pass away while the coverage is still in force, your beneficiary receives a cash benefit. Unfortunately, it does not always work as simply as you might think it should.

There are many reasons that an insurance company might balk at processing a payout. After all, the insurance company has a bottom line to protect, and paying out every claim that is filed is not the way to do that. If an insurance company can find a legal reason to deny a claim, you can count on the fact that it will do so.

Any time there are extra mitigating factors, such as potential questions about who a beneficiary might be or whether a beneficiary change was legal, it can hold up a payout or even put a claim in jeopardy.

If you believe you are the rightful beneficiary for a life insurance policy and the insurance company is not acting in good faith or is otherwise failing to pay the claim, you may need additional help. Experienced life insurance and accidental death insurance lawyers who understand these issues can fight to protect your rights and increase the chance that you get the benefits you deserve.

For more information about how we can help you, contact us today. The McKennon Law Group PC has fought many life insurance companies and we have been highly successful.

Statutes of Limitations for ERISA Claims: Critical Deadlines That Claimants Should Know

The Employee Retirement Income Security Act of 1974 (“ERISA”) governs most of the American public’s employee benefit plans, insurance, and pension benefits. It applies to most medical insurance, disability insurance, life insurance, and pension benefits held by Americans. Unfortunately, disputes over entitlement to benefits arise frequently. Even after engaging in lengthy administrative appeals, the disputes are often left unresolved. The claimant’s only recourse is to file a lawsuit. But, a plan participant must be cautious because, if they wait too long, they may lose the right to sue and be forever barred from obtaining their benefits. The most important deadline to sue over a denied claim is called the statute of limitations. Understanding the applicable statute of limitations for an ERISA claim is thus important.

When seeking benefits under a plan governed by ERISA, the two most important types of claims are claims under 29 U.S.C. Section 1132(a)(1)(B) to obtain improperly denied benefits and claims under 29 U.S.C. Section 1132(a)(3)(B) for breach of fiduciary duty and equitable relief. These two kinds of claims are very different. One seeks to have the court rule that the claim for benefits was improperly denied under the terms of the ERISA plan at issue. The other seeks to establish that the claimant was harmed because the defendant breached its legal duties in some other manner and is therefore entitled to equitable relief. Both types of claims have been addressed elsewhere in related blogs on our website. This article will instead focus on how the two claims have distinctly different statute of limitation .

ERISA does not provide a statute of limitations for claims under Section 1132(a)(1)(B). Instead, courts apply the limitations period provided by the most analogous state statute: a breach of contract claim. See Wetzel v. Lou Ehlers Cadillac Group Long Term Disability Ins. Program, 222 F.3d 643 (9th Cir. 2000) (en banc). In California, that is four years. Other states may differ.

The statute of limitations is to be contrasted with the ERISA plan’s stated contractual limitations provision that also must be complied with. Most employee benefit plans contain a provision that differs from a traditional statute of limitations. In California, California Insurance Code section 10350.7 sets the time as “90 days after the termination of the period for which the insurer is liable” in disability plans. In Heimeshoff v. Hartford Life and Accident Insurance Co., 571 U.S. 99 (2013), the Supreme Court upheld such provisions. The Supreme Court determined that a contractual limitations provision is enforceable unless there is “a controlling statute to the contrary” or the period is unreasonable. Heimeshoff, 571 U.S. at 102, 105-06. Contractual limitations periods of a mere 180 days after the claim denial have been held to be reasonable. See Sargent v. S. Cal. Edison 401(k) Savings Plan, 2020 WL 6060411, at *6 (S.D. Cal. 2020)

Importantly, when denying an appeal for benefits under an ERISA plan, the claims administrator is required to provide notice of the relevant contractual limitations period. See Santana-Diaz v. Metropolitan Life Ins. Co., 816 F.3d 172, 182-83 (1st Cir. 2016). In Santana-Diaz, the First Circuit Court of Appeals ruled that the failure to provide notice of a contractual limitations period in a denial letter rendered it unenforceable to that particular claimant. See id.

Statute of limitations for breach of fiduciary duty claims under 29 U.S.C. Section 1132(a)(3)(B) are more complicated than those for breach of plan benefits. They are controlled by a federal statute: 29 U.S.C. Section 1113. It provides as follows:

No action may be commenced under this subchapter with respect to a fiduciary’s breach of any responsibility, duty, or obligation under this part, or with respect to a violation of this part, after the earlier of—

(1) six years after (A) the date of the last action which constituted a part of the breach or violation, or (B) in the case of an omission the latest date on which the fiduciary could have cured the breach or violation, or

(2) three years after the earliest date on which the plaintiff had actual knowledge of the breach or violation;

except that in the case of fraud or concealment, such action may be commenced not later than six years after the date of discovery of such breach or violation.

Section 1113 states that a plan participant or beneficiary cannot bring a claim for breach of fiduciary duty later than either six years after the last action that constituted part of the breach of fiduciary duty, or three years after the claimant had actual knowledge of the breach, whichever is earlier. This can produce complicated and unjust situations. What if the breach occurred a decade before the harmed person learned of it? Section 1113 contains a fraud or concealment exception that stops the statute of limitations from beginning to run under certain circumstances. If the defendant actively tried to conceal their breach, then the statute of limitations is tolled until the date of discovery of the breach or violation. However, the exception’s application under other circumstances is less clear. In Barker v. American Mobile Power Corp., 64 F.3d 1397, 1402 (9th Cir. 1995), the Ninth Circuit addressed this issue. The court considered the fraud or concealment exception and found that the plaintiffs in that case had failed to invoke the exception because they failed to allege that defendants “committed specific acts of fraud or concealment.” Id. However, the court also acknowledged that:

Substantial authority indicates, however, that the exception applies only when the defendant himself has taken steps to hide his breach of fiduciary duty. Other circuits have held that the “fraud or concealment” exception in the statute incorporates the common law doctrine of “fraudulent concealment.” See Larson v. Northrop Corp., 21 F.3d 1164, 1172-3 (D.C.Cir.1994); Radiology Ctr., 919 F.2d at 1220; Schaefer v. Arkansas Medical Soc’y, 853 F.2d 1487, 1491 (8th Cir.1988). Under that doctrine, a statute of limitations may be tolled only if the plaintiff “establishes ‘affirmative conduct upon the part of the defendant which would, under the circumstances of the case, lead a reasonable person to believe that he did not have a claim for relief.’” Volk v. D.A. Davidson & Co., 816 F.2d 1406, 1415 (9th Cir. 1987) (emphasis added) (quoting Gibson v. United States, 781 F.2d 1334, 1345 (9th Cir. 1986), cert. denied, 479 U.S. 1054, 107 S.Ct. 928, 93 L.Ed.2d 979 (1987)); see Greenwald v. Manko, 840 F.Supp. 198, 203 (E.D.N.Y. 1993)

Id. at 1402. In short, the courts of appeal are inconsistent when determining whether a defendant must commit affirmative acts to conceal the improper conduct or whether conduct that simply prevents the claimant from knowing that they have a claim is sufficient. The need to isolate the underlying conduct that constitutes the violation further complicates these circumstances and is particularly problematic for the average plan participant.

This raises an additional question: Do contractual limitations periods affect claims for breach of fiduciary duty? The courts have yet to reach a consensus on this issue. Heimeshoff addressed improper denial of benefits claims. Its application to breach of fiduciary duty claims is the issue debated by the courts. Some courts have held that a contractual provision applies to a breach of fiduciary duty claim. Others have rejected that position. As of 2020, “In the seven plus years since Heimeshoff was decided, four of the eight courts that have considered this narrow issue have held that § 1113 controls.” Falberg v. Goldman Sachs Group, Inc., 2020 WL 7695711, at *4 (S.D.N.Y. 2020). Of note, however, other cases have simply ruled in a manner that implicitly holds that the contractual limitations period does not apply. See, e.g., Clark v. Provident Life, 2016 WL 11744945 (C.D. Cal. 2016); Zelhofer v. Metropolitan Life Ins. Co., 2017 WL 1166134 (E.D. Cal. 2017). The majority position is that statute of limitations provisions in a plan document do not control breach of fiduciary duty claims.

Statute of limitations and contractual limitations periods can be very complicated in their application. Whereas a claimant is supposed to be informed of the applicable deadline, claims administrators never inform claimants about the applicable statute of limitations for breach of fiduciary duty claims. At times, they also fail to address the applicable statute of limitations for an improper denial of benefits claim. The wisest course of action is to seek the assistance of experienced ERISA lawyers like McKennon Law Group PC as soon as the claim has been denied, if not beforehand. Key deadlines can be missed, and, once missed, there is little that even a skilled attorney can do to help.

Understanding the Timing Requirements for an ERISA Claim

Why Timing Matters for an ERISA Claim and What Timelines You May Need to Consider

The Employment Retirement Income Security Act of 1974 (ERISA) provides specific requirements for how most group employee benefits plans are administered. Plans that may fall under the purview of ERISA include retirement/pension, health insurance, disability insurance, life insurance, and accidental death & dismemberment insurance. ERISA protections help reduce issues related to insurance bad faith and ensure employees receive the benefits they were promised as part of their compensation packages. The ERISA regulations set out certain important timelines that insurers and claims administrators must follow. Understanding the various timelines that relate to such claims can help ERISA plan participants avoid some common issues that might increase their chance of denial or a loss in court if they need to take the matter that far.

Schedule an initial consultation with our experienced business attorneys today.

Are There Statutes of Limitations for ERISA Claims?

Whether or not ERISA claims are subject to an applicable statute of limitations is a complex consideration. The statute of limitations for ERISA claims varies depending on the type of claim. For breach of fiduciary duty claims under ERISA, the statute of limitations is generally six years from the date of the last action that constituted a part of the breach or violation, or three years from the date the plaintiff had actual knowledge of the breach or violation, whichever is earlier (29 U.S.C. § 1113). In cases involving fraud or concealment, the statute of limitations is extended to six years from the date of discovery of the breach or violation (29 U.S.C. § 1113).

For ERISA claims that do not involve fiduciary breaches, courts typically apply the most analogous state statute of limitations. For example, claims for denial of benefits under ERISA Section 502(a)(1)(B) are often treated as breach of contract claims, and the applicable statute of limitations is determined by the applicable state law governing contract actions.

The ERISA plan at issue will normally have a contractual limitations period that is the same or shorter than the applicable state law statute of limitations discussed above. If it is shorter, then a claimant would also have to meet this deadline in addition to the applicable statute of limitations period. This limitations period is typically three years from the date a notice of claim must be made under the plan. If you are not sure what the deadlines for filing ERISA claims are in your case, it may be a good idea to consult with an ERISA benefits attorney who can help ensure you file on time.

Must Your Insurance Company Operate on Certain Timelines?

Yes, ERISA timelines are dictated by the law and by the plan. Typically, plans must provide decisions about claims within a specific period of time, such as 45 days. They cannot simply ignore a claim and hope that you forget about it. However, plans can drag out the process of paying a claim by asking for additional documentation or requesting an extension. In most cases, the plan has to provide a reason for these requests, though it might simply be that it needs more time to gather or review information. The exact timeline for claims will depend on the type of coverage you have and the details of your plan agreement.

Deadlines for ERISA-Related Appeals

If your ERISA claim is denied, you can typically appeal it and must appeal it prior to filing a lawsuit. However, you must file the appeal by the relevant deadline. Again, the deadline will differ depending on the type of claim you are dealing with and the details of your plan. Commonly, appeals deadlines are 60 to 180 days from when a denial is issued or received. A lawyer experienced in dealing with ERISA cases can help you understand what the deadline is for your appeal. They can also help you gather information during that time to ensure the strongest appeal possible.

Under ERISA, a participant has at least 180 days following receipt of a notification of an adverse benefit determination to file an appeal concerning disability insurance claims. If the final day of the 180-day period falls on a Saturday, Sunday, or legal holiday, the deadline is extended to the next business day. For disability benefits, the plan must resolve a claimant’s appeal within 45 days, with one 45-day extension available for if the insurer can establish special circumstances exist for the extension. The deadline for filing an administrative appeal on a denied accidental death insurance claim is 60 days from the date of the written denial. Missing an administrative appeal deadline is as fatal to a claim as the passing of a statute of limitations with very few exceptions.

Timeline for Filing a Lawsuit After an ERISA Claim Denial

In most cases, you must go through all administrative options regarding an ERISA claim before you can file a lawsuit in the matter. This means filing a timely claim, filing a timely appeal if that claim is denied, and exhausting all appeal options. Once you do that, you may have an option to file a lawsuit if you believe you can demonstrate that the insurance company improperly denied your claim. An ERISA lawyer can help you understand what type of case you may be able to build for a lawsuit. Typically, these suits are governed by a three-year statute of limitations.

Working With an Attorney to Meet ERISA Deadlines

Timeliness is critical to success when dealing with ERISA claims. An experienced legal team can help you meet deadlines and adhere to important timelines with your ERISA claims. Some ways a legal team can help include:

Ensuring you understand the timelines in question. ERISA claims can be complex, and the information about deadlines you might find online can be confusing. Because so much depends on your individual plan and type of claim, it is important to ensure you are working with the right facts.
Helping you build your case. Whether you have a few days or a few months before a timeline, an experienced ERISA attorney can help you build a case and complete the necessary paperwork and filings to ensure your claim or lawsuit is filed within deadlines.
Supporting you throughout the process. Filing a claim or lawsuit is often just the beginning of your journey with an ERISA claim. An experienced legal team provides support for you throughout the process to reduce some stress and burden at a time when you are likely facing other stresses in life. A legal team can gather documents and information on your behalf, depose witnesses to learn important information for your case, review filings and claims paperwork, and negotiate with insurance companies.

Why Choose McKennon Law Group for Your ERISA Claim?

ERISA claims demand strict adherence to specific deadlines, and missing them can jeopardize your case. At McKennon Law Group, we understand the critical nature of ERISA time requirements and work tirelessly to ensure every step is handled promptly and correctly.

Help Navigating the Process

Our team thoroughly evaluates your claim to identify potential challenges and opportunities. By developing a tailored strategy, we position your case for success. From initial filings to challenging denied claims, we guide you through the complexities of the ERISA claims process.

Protection of Your Rights and Benefits

Insurance companies often look for ways to delay or deny claims. We act as strong advocates, ensuring your rights are protected and fighting for the benefits you deserve. With a focus on detailed legal support, we give you the confidence to move forward.

Peace of Mind

Dealing with an ERISA claim can feel overwhelming, but you don’t have to face it alone. McKennon Law Group is here to shoulder the legal complexities, allowing you to focus on what matters most—your health and well-being. Knowing that seasoned professionals are managing your case gives you the peace of mind to move forward with confidence.

Contact Our Firm Today

If you are dealing with an ERISA claim or believe you are not being treated fairly by an insurance company or employer benefits plan, our team can help. Let McKennon Law Group provide you with the legal guidance needed to navigate your ERISA claim effectively. Learn how we can help you meet deadlines, challenge denials, and secure your rightful benefits.

Contact McKennon Law Group PC to set up an appointment and find out how our team fights for you.

Understanding the Economics of an ERISA Disability Case

The article outlines the economic implications of ERISA disability cases for both claimants and plan administrators. Claimants face lost wages and financial distress due to their inability to work, affecting them and their families. Plan administrators incur administrative expenses in managing claims, reviews, and appeals. ERISA was enacted to protect employee benefit plan participants, adding complexity and economic considerations to disability insurance cases.

ERISA was enacted to protect the interests of employee benefit plan participants and their beneficiaries. Along with pension plans, ERISA also governs disability and life insurance plans offered by employers. Navigating an ERISA disability case can be complex and fraught with economic considerations that affect both the claimant and the plan administrator, and thus may have significant implications for both parties. Claimants and plan administrators alike can be heavily affected by various costs.

For claimants, costs include:

Medical Expenses: Claimants often face significant medical expenses related to their disabilities. These costs can include ongoing treatments, medications, rehabilitation, and other healthcare services. The financial burden of these expenses can be overwhelming, making the need for disability benefits even more critical.

Legal Fees: Pursuing benefits through an ERISA claim often requires legal assistance. Attorney fees can vary widely, but they are typically structured as contingency fees, meaning the attorney is compensated only if the claimant wins their case. Consider that disability benefits already amount to only a portion of a claimant’s income before attorney fees are paid.

Lost Wages: The primary purpose of disability benefits is to replace lost income due to an inability to work. Claimants may face immediate financial distress, particularly if they are unable to return to their previous employment. This loss can affect not only individual claimants but also their families, adding to the emotional and financial strain.

Costs for plan administrators include:

Administrative Expenses: Employers and insurers managing ERISA plans incur administrative costs, which include processing claims, conducting reviews, managing appeals. These costs can be significant, particularly for larger organizations that handle numerous claims.

Legal Fees and Settlements: When a claim is disputed, employers may incur legal fees defending against claims. If a case escalates to litigation, costs are incurred. Additionally, settlements represent a financial liability, particularly if they involve long-term benefit payments.

Impact on Insurance Premiums: High volumes of claims can lead to increased premiums for employers, affecting their overall financial health. Insurance providers may raise rates or adjust their underwriting practices in response to higher claim rates, impacting the employer’s bottom line.

Recoveries for claimants may involve the following:

Monthly Disability Benefits: For successful claimants, ERISA disability benefits can provide a vital source of income. The monthly payments can replace a significant portion of lost wages, offering financial stability during a challenging period.

Lump-Sum Settlements: In some cases, claimants may negotiate a lump-sum settlement. This approach can provide immediate financial relief and allow claimants to plan for future expenses. However, it is essential to weigh the pros and cons, as a lump-sum settlement may be less than the total value of ongoing benefits, even when considering net present value.

Back Benefits and Interest: Claimants may also be entitled to back benefits, along with interest, covering the period from when they became disabled to when the claim is approved. This can provide a substantial financial boost, especially if the claimant has been waiting for approval for an extended period.

Recovery of Attorney’s Fees and Costs: For successful claimants, they may recover the attorney’s fees and costs they incurred from the insurers who denied their claims. This will typically allow the disability claimants to keep all or most of their disability benefits (depending on the fee agreement they have with their attorneys). Experienced disability attorneys such as McKennon Law Group PC often collect attorney’s fees and costs when they achieve success in their ERISA disability cases.

The economics of an ERISA disability case is multifaceted, involving direct costs for claimants, administrative expenses for employers, and long-term financial implications for both parties. Understanding these economic dynamics is crucial for effective navigation of the ERISA landscape. Claimants must weigh the potential benefits against the costs, while employers should consider the broader implications of their disability policies. In this complex environment, informed decision-making can help both claimants and employers achieve favorable outcomes. If you or a loved one have made an ERISA claim for disability benefits or are considering doing so, and if you are looking for the best disability lawyers in California, the experienced attorneys at McKennon Law Group PC can help you navigate these complexities. Reach out to McKennon Law Group PC for a free consultation.