California ERISA Lawyers

Denied Group Insurance & Pension Claims

Most life, health, and disability insurance policies issued through private-sector employers are governed by the Employee Retirement Income Security Act of 1974 (“ERISA”). This federal law establishes minimum standards designed to protect employee benefits.

However, ERISA is a notoriously complicated statute, and its complexities can sometimes create legal barriers between employees and their benefits. Because of strict deadlines, specific evidence rules, and mandatory administrative steps, if your ERISA-based insurance claim is denied, you need the prompt advice and services of an experienced California ERISA claims attorney.

Our firm has been advising and representing clients covered by ERISA plans since the statute first took effect in the 1970s. We know how to navigate this complex federal law to protect your rights.

Filing Your Initial ERISA Claim: Avoiding Common Mistakes

To secure benefits through an ERISA-governed plan, the first step is submitting an accurate and complete application or claim. Any mistake could delay your benefits or result in your claim’s denial.

It is critical to avoid these common pitfalls:

Mistake: Assuming Your Evidence is Sufficient

Do not assume you qualify just because your employer says you can’t work or your doctor offers an opinion. Under ERISA, it is the insurance company, not your employer or doctor, that will make the final decision. You must build an ironclad case.

Mistake: Using Only the Forms the Insurer Provides

While your doctor must complete the Attending Physician’s Statement (APS) and other insurance company forms, this is often not enough. To ensure your health or disability claim’s approval, ask your doctor to write a comprehensive explanation of your medical condition that spells out why your claim should not be denied.

Mistake: Incomplete Documentation

At a minimum, your claim must include your own employee statement, an employer statement, the Attending Physician’s Statement, copies of all relevant medical bills/records, and properly prepared personal statements.

Mistake: Exposing Yourself to Investigation

If you file a health or disability insurance claim, you must follow your doctor’s orders, keep your follow-up appointments, and refrain from activities that your doctor forbids. Otherwise, an insurance company’s investigator may decide that you don’t genuinely need the payout you are claiming.

Mistake: Inaccurately Reporting Financial Information

Your ERISA disability benefits claim must include a full disclosure of your income and assets. While few people commit intentional fraud, inaccurately estimating or over-reporting your income can lead to the rejection of your claim.

The Critical ERISA Appeal Process

If your ERISA claim is denied, the plan administrator must send you a denial letter that includes specific details about why your claim was rejected and how to file an appeal.

You Must Exhaust Administrative Remedies

The courts generally require plaintiffs whose ERISA insurance claims have been denied to exhaust their administrative remedies—meaning you must complete at least one mandatory administrative appeal—before you may bring a lawsuit in U.S. District Court (which has jurisdiction in all ERISA matters).

The Appeal is Your Last Opportunity to Submit Evidence

The most critical rule of ERISA litigation is this: The appeal is your last opportunity to introduce evidence for a court’s eventual consideration. If your appeal is unsuccessful, you and your attorney will not be allowed to introduce additional new evidence with a subsequent lawsuit.

Deadlines and What We Do

• Appeal Deadline: You typically have at least 180 days to file an appeal, though there is no reason to delay.
• Insurer Response Deadline: The insurance company typically must approve or deny your initial claim within 45 days (extendable by another 30 days for investigation).

When we handle your appeal, we will review your claim and denial letter to determine what the insurance company believes is missing from your claim, ensure that sufficient medical evidence is presented in support of your claim, and aggressively try to have the denial reversed.

ERISA Exclusions and SSDI Benefits

Which Plans Are NOT Covered by ERISA?

ERISA does not apply to:

• Public-sector government employers (federal, state, and local).
• Employees of religious organizations.
• Individual, privately-purchased insurance policies or any benefit not offered by an employer.

Receiving Both ERISA and Social Security Disability (SSDI)

Many people qualify for both ERISA disability benefits and Social Security Disability Insurance (SSDI) benefits. However, to receive SSDI, you must suffer a “severe, long-term, total” disability that meets the Social Security Administration’s definition.

While you cannot “double-dip” from both funds, we can help ensure you receive all benefits entitled to you. If you are awarded SSDI back payments while your ERISA claim was pending:

• The insurance company will seek to recover the back payments.
• ERISA prevents the insurance company from directly suing you to recover the overpayment.
• Instead, the insurance company will reduce future payout amounts to offset and recover the overpayments.

Contact Our ERISA Claims Attorneys

The McKennon Law Group has decades of experience successfully representing California workers and their families in ERISA claims and lawsuits. We possess the abundant experience required to handle these highly technical federal cases.

If your ERISA claim for disability, life, or health insurance has been denied, call us now. Schedule a legal consultation—at no cost and with no obligation—to learn more about ERISA and your rights.

Call us at 1-800-682-4137, or complete the contact form on this website. Our offices are located in Newport Beach, San Diego, San Francisco, and Los Angeles.