ERISA Disability Insurance Claim Appeals: When Your Disability Claim is Denied

Disability insurance companies know how to use the law called ERISA when they seek to deny a claim. This is a federal law originally designed to protect employees’ retirement accounts. If your long-term disability insurance is part of your employee benefits package, it is typically governed by ERISA (Employee Retirement Income Security Act of 1974).

Long-Term Disability insurance companies use ERISA as a means of limiting your options for disability claim challenges. Courts use different procedures when deciding ERISA litigation than typical cases, often to the detriment of claimants.

Your first step following a denial or termination of a claim is to appeal the denial or termination, but that’s not something easily accomplished without a thorough understanding of what you’re up against. That is why most people turn to experienced disability insurance law firms to represent them against the strict limitations imposed by ERISA, and the seemingly limitless resources of claims personnel, investigative techniques, hired doctors, and lawyers available to large insurance companies.

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 who originally denied your claim. In reality, the insurance company will often consider the prior claim decision as support and justification to uphold the claim denial or termination.

Rules Governing ERISA Appeals Are Strict

The rules for an ERISA appeal are extremely strict, with defined time frames. During an appeal, the claimant must present factual, medical, legal and vocational evidence to demonstrate how and why they are disabled and entitled to benefits under the plan. They must show why the insurance company’s determination was improper, and what about the process was unfair.

Your group disability insurance plan will state whether or not you are permitted to file one or two appeals. Most only permit one level of appeal, and then close the administrative record.

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." Following the decision on appeal, a claimant will then be permitted to file a lawsuit against the insurance company. ERISA does not permit jury trials, so a lawsuit will be decided by a judge.

In the event that your ERISA appeal(s) are denied, and a lawsuit is filed, the court in most cases will limit their review to the documents in the “claim file.” These will be the ONLY documents that can be reviewed during a Federal Court review of an administrative appeal.

This is why the appeal is the most critical time of the claim.

We Can Help You Develop Strong and Persuasive ERISA Appeals

In order to present a powerful and persuasive ERISA disability appeal, we work closely with our clients and their treating physicians to ensure that the information developed for the appeal contains great detail and a strong articulation as to the severity and degree of impairment and the impact upon our client's functionality. We work to rebut the medical opinion offered by the insurance company or its hired doctor.

We will also develop strong support for the vocational issues, focusing upon how and why our client cannot engage in work, or cannot perform the duties of either their own occupation, or any occupation, as that term may be defined in the policy, and may differ based upon insurer. We work to rebut the vocational evidence developed by the insurance company supporting their claim determination.

Read our related blog post - Top Five Things You Need to Know About Filing an ERISA Long Term Disability

The ERISA Administrative Appeals Process Is Not Fair

The entire process is stacked against the claimant. Courts reviewing ERISA disability lawsuits often act as a rubber stamp of the claim termination or denial. The appeal is the only opportunity to create a record for litigation with the hope that the court will be receptive to the demonstration of wrongful conduct by the insurer.

Lawyers who do not practice in this specific area of the law are not likely to be familiar with the restrictions. The ERISA appeals process is a significant part of the firm's long-term disability insurance practice. We continue to refine our best practices as the case law continues to evolve. Read more about our ERISA Appeals success stories.

There are additional considerations when submitting an ERISA appeal outlined here.

Frankel & Newfield Fights for Claimants Whose ERISA Appeals are Denied

Because of our experience in this area of law, we represent clients throughout the country from our office in New York. Call us at 877-583-2524 or email us to set up a free consultation.

Jason A. Newfield

Written By:

Jason A. Newfield

Disability Insurance Attorney