ERISA - Employee Benefits

Claims and Appeals for ERISA Disability or Medical Benefits

Without question, the most important factor in getting your disability or medical benefits is ERISA's two-step benefits claim and denied claim appeals process. Under ERISA, you have the right to claim disability or medical benefits and to present arguments and evidence to the plan's administrator to prove you deserve them. If the plan administrator denies your claim, you have the right to appeal. What you do, or don't do, when you file your ERISA claim and appeal will make the difference between approval or denial of your benefit claim.

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Unless you complete and exhaust all administrative procedures, i.e., the claim and appeal processes, you will be prevented from commencing a lawsuit to seek judicial review of the insurer’s decision to deny benefits. More importantly, your claim and appeal must be thorough and persuasive, because Courts are required, by law, to give great deference to the decisions of the insurance companies, otherwise known as the plan administrators. If the plan administrator decides you are not entitled to disability benefits, the court will uphold that decision unless it was arbitrary and capricious or an abuse of the administrator's discretion. This standard means that if the administrator has substantial evidence supporting its denial, you cannot win, even if you have more and better evidence that you failed to submit on your initial claim or appeal. So, if you do not win your appeal, you might have little chance to win in Court.

Hire an Attorney Now; Don't Wait

Your disability benefits might last for years and provide you with much more income than you'd have if you don't get these benefits. The sooner you hire a skilled attorney to assist you, the better your chances of prevailing.

Great Representation Costs Money
We think you should be extremely suspicious if an attorney tells you that his or her entire effort will be spending an hour or two writing an appeal letter for you. Usually, that would prove to be a waste of your money, since, in our experience, the appeal will simply be denied. Plan administrators are not intimidated by a simplistic letter from an attorney. We recommend that you hire an attorney who will prepare a "great" appeal for you.

Prepare a Great Claim and Appeal
What is a great appeal? We organize, review and summarize all of your relevant medical records. We make sure that your doctors are communicating the nature and extent of your disability. For appeals, we study the plan administrator's reasons why you were turned down. We compare your Plan's definition of disability to this information to make sure that your case is proven. If something is missing, we do everything we can to fill the gaps. We often work with your medical professionals and explain to them how to write letters explaining their diagnosis and their conclusions in a manner which the plan administrator will understand and appreciate. Sometimes, we interview people who know you and who can aid us in telling the story of your life so that the administrator can see you as a valuable human being – not just a number. Then we typically draft an extensive claim or appeal letter incorporating all of this information.

Hold Nothing Back
If your case reaches litigation, courts will usually not allow you to introduce evidence in support of your claim of disability that you failed to include in your initial benefit claim or appeal.

Get All Your Medical Records
Getting your medical records is often a difficult and time-consuming task. As soon as you have any idea that you might be seeking ERISA disability or health benefits, you should begin locating and gathering your records; otherwise, you may find that you will run out of time to get this in for your claim or appeal. That is especially important if there are holes in your records such that we would want you to go back to your doctor or to see a different type of medical specialist to prove up a missing element of your claim.

Know What the ERISA Administrator is Looking At
It's almost impossible to know how to file an appeal if you don't know what the plan administrator has in its files. Request, in writing, a complete copy of your administrative claim file. If there is a surveillance tape on you (as is often done in disability cases), make sure you get that tape. Make sure you have a copy of the policy and a document called the “summary plan description.”

Answer the Plan Administrator's Concerns
If you are turned down, make sure you know why. Under ERISA regulations, the plan administrator has to tell you in writing specifically why you were turned down, the portions of the plan it was relying upon to turn you down, and what you need to address to have this denial overturned during the ERISA appeal. Then, it’s your job to respond brilliantly. You won't be brilliant unless you address every reason you were turned down, and why you were turned down is sometimes a very tricky analysis.

Keep Focused on Your Last Day Worked
For disability claims, the key date is your last day worked. It won't help you to prove that you were disabled a year after you left work if you cannot also show that you were disabled when you left work. Only employees are eligible for disability or medical benefits. Former employees are not.

Get an Extension If You Really Need One
Don't file your claim or appeal before you are ready, unless you just cannot help it. We often call and write to the plan's administrator to get an extension of time to get the work done to file a great claim or appeal.

Do Not Ignore Time Deadlines
Get a copy of your plan's "Summary Plan Description." This document will set out a date, if any, by when you must file your initial claim, how long the plan administrator has to respond to your claim, and the timing for filing appeals. That document will also provide useful clues as to what you must prove to get your benefits.

Social Security Awards
If you get an award of Social Security Disability Income benefits (SSDI), and if the government determines that your disability start date coincides nicely with your last day of work, or if the SSDI award otherwise complements your claim, then you should submit that award and all supporting documentation to the plan administrator so they can include it in their analysis.

Get the Help You Need
We have come to understand that people filing disability and medical benefits claims are often at a difficult crossroads in their life. You might be facing the permanent lowering of your standard of living. You might be dealing with the end of a career that you loved, or might be coming to grips with major health problems. You might be seriously depressed. All these things are to be expected, and you should never be embarrassed that you might need help or that you are have to deal with powerful emotions. So get the help you need, including hiring an attorney like us if that's appropriate.
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