The Employee Retirement Income Security Act of 1974 (ERISA) created national standards for employer pension and wellness programs. If you believe you have unfairly been denied benefits, you might need to bring an appeal. The claims process is very detailed and complicated and can only be summarized generally here.
Your employer should tell you how to make a claim for benefits. Follow the process to the letter and submit everything on time. The insurance provider typically has 45-90 days to accept or deny your claim for benefits.
If you are denied benefits, the insurer must send you a letter notifying you of the reasons why. It also must tell you the deadline for bringing an appeal. Read this letter closely, because you absolutely must meet deadlines to protect your rights.
The benefits plan is obligated to give you all relevant paperwork related to your case. As soon as you read your denial letter, you should send a letter requesting this information. Send the letter certified mail, return receipt requested. Read through the paperwork carefully and compare the information to what was included in your denial letter.
Look at every reason you were denied benefits and find evidence to counter every single reason given. For example, the plan might state that your injury isn’t serious enough to qualify for the benefit. If so, find evidence such as test results or medical records that show otherwise.
Be very organized as you gather evidence and remember to find everything that is helpful. Part of bringing a successful appeal is building up your evidentiary record and submitting it to the Plan for consideration all at once.
Remember to respond to every reason given for the denial of benefits. If you overlook something, then the Plan has no reason to overturn its decision. Always file your paperwork ahead of the deadline and provide your relevant evidence.
The appeals process is initially administrative, meaning it is handled outside of court. Only once you exhaust all administrative remedies can you file your lawsuit in court. If you jump the gun, you are only hurting yourself.
At court, the judge will determine whether or not the insurance provider wrongly denied you benefits. The judge will rely on the paper record that was developed below, which is why you needed to submit all of your evidence early in the appeal process. The judge will not let you introduce evidence and witness testimony to help bolster your case if you neglected to introduce it earlier in your administrative appeal.
Bringing ERISA claims is incredibly complicated. One mistake and you can hamstring your ability to receive benefits you are entitled to. To ensure you dot every “I” and cross every “T”, you should work with an experienced ERISA attorney. Michael Bartolic has practiced ERISA law for over a decade and is available to help you. Please call 312-635-1600 to schedule your free consultation.