WHAT IS ERISA?

ERISA is an acronym for the Employee Retirement Income Security Act of 1974.

ERISA was designed and passed in order to protect the solvency of employee pension plans. However, ERISA has been interpreted to apply to group health, life and disability insurance plans as well. As such, if you have a dispute with an insurer over benefits from an insurance policy that you received through employment, such as group health, disability or life insurance, there is a significant chance that the dispute will be governed by ERISA. Unfortunately, unlike with pension plans, the application of ERISA law to group health, disability and life insurance disputes has reduced rather than expanded the legal protections available to policyholders. For instance, under ERISA, an insured is generally not entitled to punitive or bad faith damages, is generally not entitled to a trial by jury, is generally limited to recovering policy benefits, and most importantly, an insurance company’s decision to deny or terminate insurance benefits is generally given “deference”, meaning an insured may need to prove that the insurance company’s denial or termination was not only wrong but that it was also “arbitrary” or “capricious”.

Unfortunately, these protections can encourage certain insurance companies to over zealously deny insurance claims or terminate ongoing benefits.

WHEN TO CONTACT AN ERISA ATTORNEY?

In spite of these legal impediments, there are protections available for those who have had their disability, health or life insurance benefits wrongfully denied. Please be advised that if you plan on seeking legal assistance in regards to your claim for insurance benefits, the generally accepted rule of thumb under ERISA is “the sooner the better.” This is particularly poignant during the “Appeals Process” of your claim. Whether you have had disability, health or life insurance benefits terminated or denied, you should be provided an “Appeals Period” with which to supplement your administrative record and to request that the insurer reconsider its termination or denial of benefits. This process is generally referred to as the “Appeal Process”. This is generally the most advantageous time to retain legal counsel, as this is the only time in which your “Administrative Record”, i.e. the evidence on which your claim will be determined, can be supplemented. It is also important to note that your appeal must be filed timely or else you could be barred from pursuing your claim in court.

HELPFUL HINTS

If you have had Disability, Health or Life insurance benefits wrongfully terminated or denied the following information should be helpful to you. However, please be advised that the material contained herein is general in nature and may not apply to your particular factual or legal circumstances. Therefore, you should not act on this information without seeking professional counsel.

Get a copy of your “Administrative file” or “Claims file”

In order to prepare your appeal, you should first request a copy of your “administrative” or “claims” file. Under ERISA, the plan administrator (which may be your insurance company or another company designated under the plan) is generally required to provide you with a complete copy of your administrative or claims file within thirty (30) days.

Your request should be in writing and should be sent by certified mail, return receipt requested. A review of your claims file will enable you or your legal representative to peruse all evidence that your insurer has relied upon in terminating or denying your claim. Hence, after review of your claims file, you or your legal representative should have a better idea of what documentation you may need to submit in order to support your appeal and/or to protect your rights in the event the case proceeds to litigation.

Start A Claim Journal

It is important to understand that once you have submitted a claim for insurance benefits, you have initiated a process where actions and statements have legal ramifications.

As such, maintaining a written journal can help you keep a clear legal record. This journal is for your private use and should not be given to anyone but your attorney.

You should record the date and manner of all phone conversations with your insurer, who you spoke with, what information was requested, as well as communications you receive from your employer or your insurance company. Be sure to save copies of all written documents and correspondence, as they may be vital in pursuing your appeal and/or litigation.

If dealing with a disability or medical claim, you should log all visits to treating physicians; summarize conversations that occurred during those treatments and continuously request copies of all your medical records from all treating providers. If submitting a life insurance claim, in addition to requesting copies of medical records of the deceased, be sure to keep copies of death certificates, relevant newspaper articles and his/her obituary.

Seek experienced, professional medical help, especially when pursuing a claim for disability benefits.

It is not unusual for an ERISA plan administrator to deny or terminate disability benefits based on one opinion from one doctor employed by the insurance company. This can happen even if the doctor is not a specialist, has never examined the insured, is not provided with all of the insured’s medical records and has never even spoken with any of the insured’s treating doctors. This contrary opinion should be rebutted by a better qualified, treating physician who understands the insured’s disability, is highly credible to the insurance company and who is willing to take the necessary time to outline and explain your disability to your insurance company. Therefore, before your file a disability claim, you should examine your relationship with your physician to see if he/she meets these requirements. If not, you should seek treatment from a physician who does.

If you have any questions or concerns regarding your potential ERISA claim, please feel free to call us at (561) 616-3333 for a free legal consultation.