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Do I Have to File an ERISA Appeal of a Disability Insurance Denial Before I Can File a Lawsuit?

A recent D.C. Court ruling in an ERISA long term disability denial lawsuit sparks the question: If a claim for disability insurance benefits has been denied, is the claimant required to file an ERISA appeal with the insurance company, or can the claimant bypass the appeal process and, upon denial, move forward and file a civil lawsuit under ERISA? The general answer is that in almost every case a claimant must file an ERISA appeal, but in this blog entry we will discuss some legal exceptions that could allow a lawsuit to be field with the filing of an administrative Appeal.

In the D.C. case, the Plaintiff argued that he was not required to exhaust his available administrative remedies because: 1) ERISA does not mandate exhaustion and that this requirement should be determined by the individual courts on a case-by-case basis; 2) the denial notice he received did not mention any claims procedure or appeal process, thereby excusing him from pursuing administrative remedy; and 3) pursuing administrative remedy would have been futile and that he had already attempted to resolve this matter in house before filing his lawsuit. The D.C. court found that none of the Plaintiff’s arguments were sufficient to waive the strict exhaustion requirement.

Exhaustion Requirement Under ERISA in Disability Insurance Denial Cases

The ERISA law itself does not specifically state whether a claimant is required to exhaust all available administrative remedies before filing a civil lawsuit. However, there is a long settled rule of judicial administration which mandates that no one is entitled to judicial relief for an alleged injury until such time as the prescribed administrative remedy has been exhausted. This means that because ERISA does not specifically address this issue, the exhaustion requirement will automatically be applied to all cases, except for instances where the district court, through its own sound judicial discretion, determines that the exhaustion requirement does not apply, or should be waived, for a particular case.

This leads us into the question: under what circumstances will a court determine that the ERISA exhaustion requirement does not apply, or should be waived?

Exception # 1: Lack of Meaningful Access to Higher Levels of Review

The first circumstance when the exhaustion requirement may be waived is if a claimant lacks, or is denied, meaningful access to higher levels of review. In the D.C. case, the Plaintiff tried to argue that the denial notice he received did not specifically mention the insurance company’s appeal process or claims procedure. Without being informed of the appeal process or the claims procedure, he was therefore denied access to higher levels of review of the denial of his claim for benefits. However, the Plaintiff’s argument failed because he did not claim that no claims procedure existed, but rather, the notice did not mention it. The courts have well-established that ignorance of a claim procedure does not waive the exhaustion requirement and that each individual/claimant has a duty to seek the necessary information, regardless of whether it has been made available.

Another example of this would be if a claimant tried to initiate higher levels of review procedure, but the insurance company denied or otherwise prevented the claimant from being able to proceed with the higher level review of the claim or denial.

Exception #2: The Futility Exception

The second circumstance whereby the exhaustion requirement may be waived is known as the futility exception. The D.C. Plaintiff argued that, prior to filing the lawsuit, he attempted to resolve his issue by contacting several members of his employer’s management to no avail. Therefore, to go through the administrative appeal process would have been futile because it was highly likely his appeal would be denied. However, the futility exception has very strict standards. It is not enough for an adverse decision to be “highly likely”. Instead, it is required for there to be a certainty of an adverse decision. An administrative process could be deemed futile if, for example, it would require such considerable time to complete that the Plaintiff’s rights would be lost by the inability to make a speedy decision. Or, if a claimant was notified unequivocally that appeal of a denial would not be considered or would not alter the decision to deny.

Because the D.C. Plaintiff was not able to present sufficient arguments to the court to support his contention that the exhaustion requirement should be waived in his case, as well as for several other reasons such as failing to move for leave to amend his complaint and failure to state a claim, the court dismissed the Plaintiff’s lawsuit with prejudice and, upon motion for reconsideration, the dismissal was upheld. As a result of this plaintiff and his disability attorney filing a premature lawsuit, the claimant will be forever barred from having his disability denial heard by any court. The claimant’s claim is over and he has not further rights.

How to Ensure that You Fulfil the Exhaustion Requirement

This case teaches us that there are several crucial steps that must be taken if your claim for disability benefits has been denied, and even before that point, prior to submitting your initial application for benefits. First and foremost, read your Plan and understand your insurance company’s process for reviewing claims and the administrative appeal process that is available if/when the decision is made to deny benefits. Second, if your claim is denied, the denial letter should include language explaining your right to file an appeal. Appeals are typically time-barred and you only have a certain amount of time once your claim has been denied to submit additional information to the insurance company and request they reconsider their decision to deny your benefits. If the denial letter does not include this information, it is your duty to either read your Plan and learn what the procedure is to appeal a denial, or contact your claim representative and ask them to explain what remedy is available to you since your claim was denied.

If you file an Appeal, the disability company has 45 days to make decision and then for exceptional cause they can request two additional 30 day extensions. Once the time period is elapsed, if a decision has not been made the case is still not clear in every court as to whether a lawsuit can be filed. In our cases, if a disability company does act in accordance with the time restraints provided by the ERISA statutes, then we will file a disability lawsuit before a final decision is returned.

The best solution, if your claim for disability benefits has been denied, is to make sure to contact an experienced ERISA disability attorney. If you have any questions regarding your rights under a short or long term disability policy please contact Attorneys Dell & Schaefer for a free consultation.

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Reply

Sent on July 5th 2024 by Attorney Gregory Dell

David:

It’s horrible that Hartford did that to you.

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Reviews from Our Clients

S.S.

I am a physician in my 30s who was practicing in my hospital based medical specialty until my Multiple Sclerosis diagnosis began to severely limit my physical ability to work.

My husband and I were obviously in distress at these very unwanted life changes and frankly overwhelmed with the possibility of a long and traumatizing legal battle ahead of us. We knew we were legally entitled to benefits through the separate private individual and employer based ERISA disability insurance policies we had, but even cursory research and discussion with colleagues made it clear that insurance companies will strategize with their own legal teams to find ways to not pay out benefits. We found many before us who had fallen unwittingly into legal pitfalls that prevented them from ultimately obtaining benefits. We realized we needed to seek legal counseling.

We found Dell Disability Firm through their youtube channel where their associates have videos discussing the legal intricacies and latest developments in private disability law. I was impressed by their dedication to the field and reached out through their website to request a free consultation.

We were delighted to hear that Mr. Steven Dell himself would be willing to take our case and felt assured that we would be represented by the best of the best.

We have not been disappointed in our expectation and have, in fact, been consistently very impressed. Steven Dell is clearly both knowledgeable and wise about dealing with these issues but more importantly, has shown kindness and impeccable honesty at each step of the way.

Merlin has demonstrated a very high capacity for organizing and handling the endless myriad of documents and communications between us and the insurance companies. She has also been very compassionate, accessible and forthcoming in dealing with our many anxiety fueled emails and telephone calls to her and we are very grateful for her involvement.

For over 7 months, we have been working closely with Steven Dell and Merlin Bryan from Dell Disability Lawyers as they have guided us through the process of review and initial application for benefits from our two insurance policies (Hartford and Ameritas).

We are happy to announce we just received approval of claim from the Hartford insurance company.

At this time we are still working with this firm as we await the final decisions from Ameritas policy that we are hopeful will have a similar outcome.

As anyone with a chronic and progressive illness can tell you, time becomes a very precious commodity. Through their representation, Dell Disability Associates has allowed us to focus the majority of our time enjoying the time and function I have left while resting assured that our disability case laid in competent and caring hands.

The truth is that no amount of money can make up for what we have lost, but it is a huge comfort to have a team like Dell Disability Lawyers at our sides to help us ensure we will be able to continue to care for ourselves and our families.

We highly recommend Dell Disability Lawyers, Mr. Steven Dell and Ms. Merlin Bryan to handle your disability insurance claim.

Thank you Steven, thank you Merlin!

We will certainly plan on leaving another review for completeness once we have our final decision from Ameritas.

Paula B.

I have been working with Dell Disability Lawyers for the past 5 years concerning my disability as it pertained to my employer. I have been more than pleased with them the entire time. They have always kept me informed of any paperwork needing completed or any changes coming ahead. Nothing has been a surprise. I would recommend them to you to help with your disability case if you’re trying to dip into the policy you’ve been paying for.

Michael M.

I am a physician who has been disabled for over 10 years. During this time I have been represented by Cesar Gavidia and his assistant Danielle Lauria. Their representation on my behalf has allowed me to concentrate on dealing with my disability/disease process and all associated complications and not having to deal with all the things that are necessary in a disability claim. Based on my personal experience from many years of practicing medicine I would consider their work product, insight and effort in the disability claim procedures to be superior. I would recommnend them, which I have done, with my highest level of confidence. In short, you well served with this practice.

Dan P.

I had to retire from my career due to a bad back that restricted me from performing my duties. I had LTD insurance and after a few years of receiving monthly benefits from this insurance company, they notified me that my benefits were terminated stating that I don’t qualify due to my duties not fitting into some “national job description” and a nurse had deemed me eligible to go back to work. Its a crushing feeling to have this told to you over the phone with hardly any information given. Luckily, I came across Dell Disability Lawyers and spoke with Attorney Palamara who calmed me down and stated they would take my case. Within a couple of months my benefits were restored, and I had piece of mind. I cannot thank Attorney Palamara and the staff enough at Dell Disability for their professionalism, no nonsense approach, personal and timely communication and quick ability to litigate my case.

Jen S.

I wanted to thank Mr. Symonds and his legal assistant Sonia for their professionalism, guidance and dedication towards my LTD claim. Going through the denial process on my own was going to get me sicker and knew it was time for help right away. I reached out to Dell Disability Lawyers for assistance and not too long after my call, I was connected with Sonia – Soon after that, I was talking about my case with Mr. Symonds. After a long and tedious process with the LTD insurer, we won the case. The wait can absolutely be lengthy, but in the end, it was all very much worth the fight. Thank you both so much for all that you have done for me! I also want to thank those who assisted in keeping me updated, as needed. Highly recommended for anyone who is going through the brutal process of an LTD denial.

Carl G.

I would like to thank Dell Disability Lawyers for taking care of my case and help me get the insurance coverage that I was rightfully in need of. Specially, I would like to thank Lawyer Alexander Palamara and RIGHT-HAND legal assistant, Sonia Nogueira, who made this process less stressful. They answered all my questions and kept me informed every step of the way.

Don’t get me wrong. They never promised or told me that I was going to win my case, as no one can guarantee that for you. What they did do, was letting me know that they were working hard for me and to keep positive. Something that I recommend everyone to do is to subscribe to their YouTube channel. That will give you an idea on how they operate and why they (for most of their cases) win their cases.

Since I was awarded disability, I am still having surgeries and thanks to Dell Lawyers, I’ve been able to cover all those expenses.

Warm regards to everyone at Dell.

Clarisa B.

I’m so very Grateful and Thankful for the team at Dell. They worked tirelessly to get the best outcome for me. I’m so glad that I found them!!

Carole S.

Exceptional efficient and professional service from Jay Symonds and Sonia Nogueira. They were both so helpful and knowledgeable and navigated me through a very stressful and difficult situation with New York Life.

K. S.

Awesome team. Jay and his team, Sonia and Francesca, truly care. This team is very Professional and quick to respond. Jay always provided answers in detail to my questions. I strongly recommend Jay Symonds.

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