Understanding ERISA Claims And Appeals: A Question-Answer Guide

In this article, you can discover:

• The process of requesting a second-level review for an ERISA claim denial.
• How to file an ERISA appeal and the additional evidence needed for a successful appeal.
• The federal-level appeal process and the importance of hiring an attorney for ERISA cases.

Can I Request A Second Level Review If My Initial ERISA Claim Is Denied?

The claim and appeals procedures are outlined in your insurance policy or the summary plan description for your benefit plan. Most plans require one level of appeal, while others require a second level before you can bring a lawsuit. Be sure to follow the guidelines of your specific disability plan.

Will The Denial Letter Tell Me Exactly Why My ERISA Claim Was Denied?

The denial letter must provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied. It must set out specific reasons for the denial and be written in an understandable manner to the participant. Essentially, the denial letter must provide claimants with specific reasons for their denial or termination of benefits.

How Do I File An ERISA Appeal?

A comprehensive appeal should include medical, vocational, and legal analysis. It is highly recommended to hire an attorney to file your appeal, as your appeal under ERISA will be the last chance you have to submit evidence for the judge to review in case your appeal is ultimately denied.

What Additional Evidence Should I Provide To My ERISA Attorney To Help My Appeal?

Provide your attorney with information about your current treating sources, medical providers, and supportive claims. Ensure they have your claim file and policy, and be prepared for the fact that additional testing may be necessary depending on the reasons for the denial. For example, if the denial is due to a lack of objective evidence for a physical condition, you may need to undergo a functional capacity evaluation.

What Are The Most Common Reasons For Denial Of An Appeal At The Insurance Level?

The most common reason for denial is not meeting the definition of disability. Other reasons include failing to meet the requirements of being unable to perform any occupation after a specified period, usually two years.

Can Anyone File For An Appeal At The Federal Level?

After exhausting the administrative-level appeals with the insurance company, you can file a lawsuit in federal court. You can appeal to the circuit court if the lawsuit is denied at the court level.

Can I Submit Additional Evidence At The Federal Level Or Under Reserve Appeal?

Most of the time, you cannot submit additional evidence after your initial appeal. If the standard of review is based on an abuse of discretion, the court will only review evidence that was in front of the insurance company when they made the decision. However, if the standard of review is based on a “de novo” review of the case (meaning “fresh look”), the court may review new evidence.

Do I Need An Attorney To File For An ERISA Appeal At The Federal Level?

While it is possible to file an appeal yourself, it is not recommended due to the complexities of ERISA law. ERISA cases are typically decided at the summary judgment level without a trial. The court will review the briefs, and the claim file, and hear arguments based on that. Proceeding without an attorney could be detrimental to your case.

For more information on the Denial Of An ERISA Claim & Appeals Process, a free initial consultation is your next best step. Get the information and legal answers you are seeking by calling (352) 577-7746 today.