The Employment Retirement Investment Security Act, more commonly known as (ERISA), protects employee benefit plan participants and their beneficiaries. The legislation provides pension and insurance companies with guidelines on how to administer employee benefit plans for private employers, including disability and health plans.
If you file a disability claim with your employer’s insurance provider and it is denied, the appeals process can seem overwhelming. It is important to avoid mistakes when you appeal,and this article can take you through the process and explain your next steps. First, we’ll discuss filing an ERISA disability claim. Next, we’ll describe what happens if your claim is denied and how the appeal should proceed. Finally, we’ll discuss filing a suit in federal court if your ERISA appeal is denied.
Filing an ERISA Disability Claim
ERISA requires employers to provide their employees information about their plan benefits, including disability benefits. This should include a detailed explanation of what is covered under the plan, directions on how to file a claim, and an outline of the appeal process if a claim is denied. When you file a disability claim, ERISA rules allow the insurance provider 45 days to approve or deny the claim, with an option of 2, 30-day extensions if they notify you.
Appealing an ERISA Disability Claim
1. Read and Understand Your Denial Letter
If your claim is denied, the plan provider must clearly explain the reason for the denial in writing, as well as how to appeal. Pay close attention to the provider’s reason for denying your claim, as this may determine how you need to proceed in an appeal. For example, if your denial letter indicates your claim lacked objective documentation of a disability, you might want to include lab tests, MRIs, or additional x-rays.
Make sure you also request a copy of your disability claim file from your plan provider. They are required by law to provide you a copy for free.
The denial letter should also clearly explain how you can appeal and provide you with the option of submitting additional information or evidence, as well as responding to the reasons for the denial. You will have 180 days to appeal the disability decision and the plan administrator will have 45 days to decide your appeal.
2. Stack the Administrative Record While You Can
ERISA sets a 180-day time limit for you to appeal a claim and another 45 days for the provider to decide the initial appeal, with an additional extension permitted. If the provider denies your appeal, you may file suit in federal court under ERISA. However, this lawsuit is essentially like an administrative law hearing. You won’t be allowed to submit new evidence or testimony. Rather, the judge will make a decision based solely on the evidence presented in the initial claim and the initial appeal.
What does this mean? Your appeal is the last opportunity you will have to present your claim, medical records, and any other additional evidence to support your claim for disability.
3. Hire an Attorney
Because you may not be able to submit additional evidence after you’ve filed your disability appeal, it’s important to consult an experienced ERISA attorney as soon as your initial disability claim is denied. While the clock is ticking on your time to file an appeal, a savvy attorney can ensure that you submit the best possible support for your claim. Even if your appeal is denied, a strong appeal is much more likely to succeed if you take it to federal court later on.
Filing an ERISA Suit in Federal Court
If your appeal is denied, you are entitled to file an ERISA lawsuit in federal court. There are two standards of review in federal ERISA claims. Under the de novo review standard, the court must look at the information in the administrative record without giving any deference to the decision of the plan administrator in your claim. Under the “abuse of discretion” standard, the court gives some deference to the decision of the plan administrator.
Determining which standard of review applies in a federal ERISA claim depends entirely on the language of your disability policy and where you live. If the plan confers discretion upon the claim administrator to determine your eligibility under the policy, the “abuse of discretion” standard will apply. However, the court must review a claim de novo unless the plan unambiguously confers this discretion upon the plan administrator.
The rules in California are slightly different. New ERISA policies are no longer permitted to grant discretion to determine benefits to the plan administrator. Obviously, this is a complicated area of law and you should consult a practiced ERISA disability attorney to ensure that you know how to proceed. Understanding the standard of review that will apply to your trial can be crucial to the ultimate success of your disability claim.
If the de novo standard of review applies to your case, the judge may look at information outside of the administrative record of your claim and appeal, such as deposition testimony. But it is by no means assured that a judge will consult evidence extrinsic to the claim and appeal. Rather, the judge will do so if she can’t complete an adequate review of the claim without doing so. This underscores the need for a competent ERISA claim attorney on your side.
If you believe you’ve been wrongly denied disability benefits under ERISA, please call our toll-free number 844.UNDERWOOD (844.863.3796) or send us an email to arrange your free consultation with our lawyers. Se habla español.
The Underwood Law Office in McKinney, Texas law firm serves all of Dallas and Fort Worth, including Plano, Frisco, Allen and McKinney. Our Huntington, West Virginia attorney office serves all of West Virginia.