Where Must Someone First File An Insurance Denial Appeal?

The appeal must be filed according to the procedure, which is set out in the Summary Plan Description, which all ERISA plans must issue. Typically, the appeal is filed with the insurance company. Some plans, typically self-funded, require the appeal to be filed with the plan administrator.

Can I Add Missing Evidence And Provide Arguments To The Insurance Company At The Appeal Stage?

Yes, an appeal is your best, and frequently only, opportunity to add evidence to the record being considered by the insurance company.

How Long Does It Generally Take To Get A Claim Decision At The Administrative Level?

Claimants should expect a decision in between 45 to 90 days.

Are Most Claims Approved Or Denied At The Administrative Level?

A well-supported claim will have better chances of approval than one which has been submitted in a haphazard or hurried way.

Will I Find Out Exactly Why My Appeal Was Denied?

Yes, the insurance company will issue a letter explaining the reasoning a claim appeal was denied. You can request a copy of the insurance company’s claims file, which typically has additional insights into why the claim was denied and must be provided upon request.

If The Insurance Company Reviews My Claim Appeal And Issues A Denial As Their Final Decision, Is That The End Of My Case?

If an appeal is denied, at that point the claimant may file a complaint in the United States District Court.

Is It True I Must Exhaust The Pre-Litigation Process Before Filing A Lawsuit Against The Insurance Company?

Yes, before going to court, claimants have an obligation both under the terms of the plan, as well as under ERISA claims regulations, to file a claim, wait for a decision, file an appeal, and wait for the final decision.

Is It Always Worth Taking Your Insurance Denial Case To The Federal Lawsuit Level?

The decision to initiate litigation in federal court frequently includes a consideration of the dollar amount of benefits at stake. Frequently, a federal lawsuit is your only remaining option when a claim is denied but does the benefit outweigh the cost and hassle of bringing litigation?

As An Attorney With Extensive Experience With Insurance Claims Litigation, What Tells You If A Client Has A Good Case That Should Move Forward To File A Lawsuit?

Ultimately, the best litmus test for bringing a case to court for a claim denial is whether the claimant suffers from a genuine, authentic disability. If the claimant has an honest-to-goodness disability, then it is more likely that justice will be had in court. Some of the other factors that go into determining potential success in court include whether the insurance company violated ERISA claims regulations, the quality of the medical staff that reviewed the claim, and if the insurance company separated financial considerations from its fiduciary obligations.

After Exhausting Appeals At The Admin Level, How Long Do I Have To File A Lawsuit Against The Insurance Company?

The Summary Plan Description of your plan or insurance policy will identify a time limit for pursuing litigation for a denied appeal. If that document is quiet on the matter, then you have as long as you would have under your state’s contract law to file a lawsuit.

How Do I File A Federal ERISA Lawsuit?

A lawsuit is initiated by filing a complaint in court, along with paying the complaint filing fee. Currently, that fee is $400.00.

For more information on Filing an Appeal After ERISA Claim Denial, a free initial consultation is your next best step. Get the information and legal answers you are seeking by calling (352) 577-7746 today.