Put An Experienced Legal Team On Your Side

What to do when denied benefits governed by ERISA

by | Nov 6, 2023 | ERISA

The Employee Retirement Income Security Act of 1974 (ERISA) was a landmark piece of legislation that helped to establish financial protections for those in well-compensated positions. Employees ranging from executives to factory workers often have complex benefit packages that may include employer-sponsored health coverage, retirement benefits and even disability insurance.

Given that these benefits relate to someone’s employment, workers often trust that their employer will look out for their best interests, but that has not historically always been the case. Therefore, lawmakers created ERISA to better ensure that workers receive the benefits they deserve based on their employment arrangements.

If someone with ERISA disability benefits files a claim and gets rejected, ERISA guarantees the right to appeal.

What the ERISA appeals process involves

Those administering policies governed by ERISA should focus on the protection of the insured party above all else. The law imposes a fiduciary duty on administrators working for the insurance company. They have an obligation to put the best interests of the covered worker ahead of their own priorities. They also have to fairly handle appeals pursued by those initially denied benefits.

The ERISA appeals process begins with applicants or the attorney representing them sending information to the insurance company. They will then seek to establish factual evidence supporting the claim. Typically, people will need to obtain supplemental information because what they submitted with their initial claim was insufficient.

An attorney can also ask for access to certain insurance records through the discovery process which may help if litigation is necessary to resolve the matter. Provided that the claim is valid and that someone does have a medical condition that would qualify them for benefits according to plan documentation, the appeals process can be very useful. Applicants usually have either 60 or 180 days to initiate the appeals process depending on company policy.

Small mistakes, like missing deadlines, could compromise someone’s ability to obtain the benefits they deserve. Generally, if applicants believe that litigation may be necessary in the future, they will need to be very careful to submit as much documentation as possible during the appeal so that they can include it in the litigation later. Only one appeal is available, and litigation will be the next step if the appeal is not successful.

An individual who is already dealing with a disabling medical condition may understandably find all of these requirements and rules very difficult to navigate. As such, seeking legal guidance can make all the difference for someone seeking ERISA-governed disability benefits because of a disabling medical condition.