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Group / ERISA Claim Denial


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If your ERISA governed long-term disability claim has been denied following your initial application for disability benefits, ERISA regulations require the insurance company to establish and maintain a procedure by which a claimant shall have a reasonable opportunity to appeal an adverse benefit determination to an appropriate named fiduciary of the plan, and under which there will be a full and fair review of the claim and the adverse benefit determination.

Your disability plan will provide language as to whether or not you must file one or two appeals, before you can file a lawsuit. The insurance company is required to maintain an internal appeal review process so that the insurance company employee reviewing each appeal is completely independent of the employee that originally denied your claim. The idea is that a claimant is supposed to receive a full and fair review by the insurance company when an appeal is filed.

The terms of your long-term disability plan will specify the number of Appeals that are required and the total number of Appeals that a claimant may file. An insurance company can not require the filing of more than two appeals. The information submitted in an ERISA disability Appeal is extremely important, as all of the documents submitted become part of what is known as the “administrative record”. In the event that your ERISA appeal(s) are denied and a lawsuit is filed, the court in most cases will be limited to their review of the administrative record. ERISA does not allow for a jury trial, therefore if a lawsuit is filed it will be decided by a Judge.

A non-jury ERISA trial is usually a disadvantage for a claimant, because the Judge does not get to hear live testimony and the Judge is basically just reviewing documents. When submitting an Appeal it is essential that a claimant submits every piece of information in support of a claim for disability benefits that the claimant would want a Judge to consider. Attorneys Dell & Schaefer prepare all of our client’s appeals in anticipation that a lawsuit may be filed if the Appeal is denied.

In order to present our client’s appeal in a light most favorable to the insured, Attorney’s Dell & Schaefer work very closely with our clients and their treating physicians, to ensure that the appeals are submitted with an overwhelming amount of information and detail. In most disability appeals, Attorney’s Dell & Schaefer will retain a vocational expert in order to determine what vocational skills a claimant can perform in light of the claimant’s medical restrictions and limitations. The vocational expert will also perform a labor market study in order to determine the availability of specific jobs in a particular market. In some cases, Attorneys Dell & Schaefer will retain a medical doctor to review all of our client’s medical records and make recommendations regarding additional evidence that would strengthen our client’s claim.

ERISA provides extremely strict guidelines and deadlines for disabled claimants seeking disability insurance benefits under their group policies. If sufficient information is not submitted within these timelines, a claimant may be forever barred from introducing the documentation to prove their disability. The disability insurance company is required to give a claimant 180 days from the date of initial denial to submit a first appeal. While 180 days seems like a long time to prepare a disability appeal, most of this time is required to submit an appropriate appeal. The appeal process is timely because it often takes time to receive all of the claimant’s medical records and to review the entire claim file provided by the disability insurance company.

Additionally, if a claimant undergoes additional medical treatment or diagnostic testing during the 180 days, it will generally improve the claimant’s chances of winning an Appeal by providing this new medical information. The disability insurance company has 45 days to respond to a claimant’s Appeal, however they may request an extension for good cause. Attorneys Dell & Schaefer understand the importance of trying to obtain benefits for our clients in an expedient and efficient manner.

Frustrating as it may seem, the disability carrier will not tell you what is necessary to perfect your claim. Moreover, group disability income policies are drafted with ambiguous and confusing contractual terms. These ambiguities provide insurance companies with multiple reasons for delaying and denying disability income benefits. Furthermore, most policies provide the insurance company with full discretion in deciding whether sufficient information has been provided by claimants prior to approving a claim. Given the complexity of the legal issues involved and the tendency of insurance companies to vigorously defend claim denials, evaluation of any potential legal claim on behalf of an insured should be handled by a law firm experienced in ERISA disability insurance claims.

Attorneys Dell & Schaefer are available to provide you with a free consultation and review of your long-term disability policy. Please keep in mind that there are time deadlines with ERISA disability claims and we must have sufficient time to evaluate your claim and take the appropriate legal actions on your behalf.