ERISA Denials Are Not the End of the Road

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If a plan administrator initially denies your disability, health or life insurance benefit claim, you should never take “no” for an answer. Under the Employee Retirement Income Security Act of 1974 (ERISA), you have certain rights when your claim is denied.

ERISA requires a very specific process for claims and appeals, but offers significant opportunities to overturn an initial denial. First, someone other than the person who issued the initial denial must review your appeal and must give no deference to the prior decision. Second, the carrier must identify the specific information that is requires in order for the claimant to perfect the claim and provide an explanation of why the information is necessary. Third, the appeal process presents the claimant an opportunity to provide the carrier with additional medical records and expert reports that support the disability claim and which may not have been submitted in the original claim process.

In general, the ERISA appeal process includes the following steps, all of which must be completed within the 180-day deadline:

  • Requesting plan documents — The insurance policy and other plan documents provide valuable information about the benefits you are entitled to, the claim administration and appeal procedures and the parties responsible for making claim decisions.
  • Obtaining your claim file —We request your entire file from the insurance company, including medical and employment records, expert testimony that was considered and internal records, such as telephone logs and emails. The file may reveal the plan administrator’s basis for denying a claim, erroneous or missing information and even non-compliance with federal laws.
  • Reviewing the denial letter — Carefully reviewing the initial claim denial letter helps determine the strategy for successfully pursuing an appeal.
  • Documenting your claim — It is important to gather as much documentation as possible to support your claim. Persuasive evidence includes opinion letters from qualified medical providers, medical literature and witness statements from employers, co-workers, friends and family.
  • Drafting the appeal letter — The appeal letter explains why the plan administrator erred in denying the claim, including policy misinterpretations, flawed medical or vocational assessments and improper claim procedures. The letter also outlines any new evidence submitted, including medical opinions and details about the claimant’s daily life.

If your appeal is denied, the plan administrator must provide written notice, which explains the reasons the claim was denied, describes any additional appeal procedures offered by the plan, and confirms your rights to seek judicial review of the decision. The internal appeal process must also be exhausted before any court action can be filed.

At Michael Sepe, LLC, our New York insurance attorneys have extensive experience with the ERISA appeals process and work diligently to obtain the best possible resolution to your claim.