ERISA Appeal Best Practices
Experienced ERISA Denial of Benefits Attorney
The Employee Retirement Income Security Act (ERISA) was enacted in the 1970s with the intention of protecting plan beneficiaries from fund mismanagement and fiduciary manipulation, but has now grown into a much broader regulation that covers all aspects of the benefits claim submission and administrative appeal (through Department of Labor regulations), and litigation processes.
If you are a plan beneficiary in an employer-sponsored benefit plan (e.g. disability, life, retirement, health, etc.) then there’s a good chance that your benefits are governed by ERISA–the unique set of rules that apply to such plans. These rules can be confusing for some, and rightly so. Many first-time benefits claimants do not realize that the path to recovering benefits can be quite different depending on whether their plan is ERISA-covered or not.
We encourage you to get in touch with Bryant Legal Group, P.C. for assistance. Our attorneys have worked with numerous clients at every stage of the ERISA benefits claim process, and are familiar with the unique rules, challenges, and opportunities associated with such disputes.
Many benefits claims are initially denied, whether or not the governing policy falls under ERISA. Too often, when a benefits claim is denied, the plan beneficiary resigns themselves to the determination made by their insurer and does not properly consider their options.
It’s important to understand that an ERISA denial of benefits itself is not fatal to the underlying claim — insurers frequently deny reasonable benefits claims due to minor procedural errors, or under the auspices of some barely-legitimate justification. This is a sensible strategy for the insurer, of course. If the insurer can coax a significant percentage of plan beneficiaries into accepting a denial of benefits (or a reduced benefits payout), they can improve their profit margins.
The ERISA appeal process is a critical tool for challenging the adverse determination of an insurer and securing the benefits that you’re owed pursuant to the plan. When navigating the appeal process, however, you’ll want to keep in mind various “best practices” that will maximize the prospect of a successful recovery.
Consider the following.
Request Relevant Plan Documents
You have a right to request and receive all relevant ERISA plan documents (including the Summary Plan Description (SPD)) before you submit your initial claim for benefits. However, if you haven’t done so and your claim has already been denied, you can still request these documents.
The SPD (and other documents) includes valuable information regarding the administrative appeal process and various procedural requirements that could have a significant impact on the successful and timely recovery of benefits.
For example, the SPD might impose specific procedural requirements with regard to the “required documentation.” Failure to include such documentation could lead to a denial (or affirmation of denial). Alternatively, the SPD might impose a shorter limitation period on filing your lawsuit. Thus, after you have fully exhausted the appeal process, you could be facing a serious time crunch.
Knowing what you’re dealing with beforehand will almost certainly help in guiding how you to advance through the appeal process and how you resolve the dispute in the event that the insurer affirms their earlier adverse decision.
Exhaust Administrative Remedies Before Moving Forward
Under ERISA, plan beneficiaries must fully exhaust their administrative remedies before they can move forward with a lawsuit. Generally, this means the completion of the internal appeal process as detailed in the plan documents.
ERISA plans can vary quite substantially in terms of what they require of plan beneficiaries — for example, some plans require that the plan beneficiary go through two separate rounds of administrative appeal procedures before they are deemed to have fully exhausted their remedies (giving them a right to pursue litigation).
Having to go through the administrative appeal process is not necessarily a negative. Though it is rather complex — and it is important not to underestimate the complexity, specificity, and formality of the procedures required of policyholders going through the appeal process — an experienced ERISA denial of benefits attorney can potentially help you secure a favorable resolution before litigation is an option.
Though the internal administrative appeal process may seem as though it is fundamentally biased against the policyholder, there are limitations on the insurer that they must be careful and cognizant of. If an insurer affirms their original denial of benefits, for example, but there is no reasonable justification for them to do so, then they may be vulnerable in subsequent litigation (which could be much costlier for them than simply resolving the benefits dispute during the appeal process).
Make Sure to Handle Claims in a Timely Manner — Appeals and Lawsuits
Timeliness is a critical component of a successful benefits claim. Failure to take action in a timely manner (accounting for various procedural deadlines) could lead to an automatic denial or further delay the processing of your appeal/case.
Once the insurer has denied your initial claim for benefits by sending you a formal denial letter, you will have 180 days to file an internal administrative appeal. Following that, the insurer will have just 90 days to respond (and in fact, that response time is reduced to just 45 days for ERISA disability claims). Insurers sometimes delay their processing by requesting extension periods (they may request multiple extensions of 30 days each). You can challenge the insurer’s request, however, if there is no reasonable justification for them to require an extension.
Given the range of procedural factors involved, it’s encouraged to seek professional legal assistance as early as possible to ensure that you do not “waste” valuable time and potentially run afoul of the deadlines.
Nexus Between the Exhaustion of Claims Procedures and Litigation
Once you’ve exhausted your claims procedures (i.e., submitted a claim for benefits and challenged their denial through the administrative appeal process), then you’re entitled to file a lawsuit against the insurer for damages. Deadlines may have a significant impact at this juncture.
Generally speaking, the statute of limitations for an ERISA benefits lawsuit is detailed in the summary plan description and often starts to run from the date of the qualifying “loss.” Thus, once you have gone through the submission and administrative appeal process, that time spent on those processes reduces the time remaining in your statute of limitations period. Whatever remains is the amount of time you have to bring a lawsuit against the insurer.
Reasonable Limitations Period
Insurers do not have absolute discretion when it comes to imposing shorter limitations periods on ERISA plan beneficiaries. They may only impose “reasonable” limitations periods. What is reasonable is a circumstantial determination — for example, if an insurer imposes a one-year limitations period for ERISA disability benefits, and you have only three months left to file a lawsuit (after exhausting all administrative remedies), reviewing courts across the country has found that this type of remaining time period is reasonable.
Building Comprehensive Documentation is a Must
Comprehensive documentation is fundamental to a successful ERISA benefits claim. In fact, many ERISA benefits denials are couched in justifications that relate to a lack of supportive documentation, even if you believe that whatever you submitted is sufficient for the insurer to make a favorable determination. For example, the insurer might argue that your failure to include a written statement from your physician (relating to the details of your condition and the impairments caused by such condition) is enough to deny disability benefits.
Comprehensive documentation varies from plan-to-plan, which is why it’s so important to evaluate (with the aid of a qualified attorney) the policy and the procedural requirements therein. For example, your plan may require a vocational evaluation of your future career prospects, whereas another ERISA disability plan may not require such an evaluation. In the ERISA healthcare context, treatment forms, diagnostic evaluations, medical bills, and other records may be required.
It’s considered good practice to overextend yourself and construct a more comprehensive record, even if certain documents are not specifically required (in the ERISA plan) by your insurer. Minimizing the “gaps” in your administrative record can not only increase the chance that your appeal process is resolved favorably but can help you in subsequent litigation (as the administrative record may not be supplemented after the administrative claim and appeal processes are completed).
Because the administrative record — your supportive documentation — cannot be supplemented after the claim and appeal processes are fully exhausted, it is strategically sensible to consider the possibility of a lawsuit, even while the appeal is ongoing. Skilled attorneys anticipate litigation, as one cannot rely on a favorable result in the internal administrative appeal process, no matter how confident you may be given the evidence you have put forth.
So, what sort of documentation might be required of you? In the ERISA disability context, it will help you to secure:
- Medical records
- Vocational records
- Work history info
- Completed impairment forms
- Written statements from relevant parties (i.e., physician, employer, colleagues)
- Vocational evaluations
- Functionality evaluation from a physical therapist
- Personal financial information
- And more
If you are attempting to secure healthcare benefits, by contrast, you might need documentation that clearly illustrates the “medical necessity” of the treatment you have undergone (diagnostic, surgical, rehabilitative, and otherwise).
Contact an ERISA Denial of Benefits Attorney for Guidance on the Appeal Process
If you’re planning on submitting a claim for benefits under your ERISA-based plan or have already submitted such a claim (and been denied), then the next steps may be overwhelming and confusing. The claim submission and appeal process can be quite complex but is necessary for securing one’s rightful benefits. We therefore encourage you to speak to an experienced ERISA denial of benefits attorney as early as possible, so that you can ensure that all the procedures are effectively handled.
We can help.
Bryant Legal Group, P.C. is a boutique, Chicago-based insurance litigation firm. Our team of attorneys has many decades of experience representing the interests of insurance policyholders — including those whose plan falls under federal ERISA regulation — in disputes against their insurers.
We provide truly comprehensive, end-to-end legal advocacy. Whether you are just beginning to submit your initial claim for benefits, evaluating the possibility of an administrative appeal, or pursuing a lawsuit, we will guide you every step of the way. It is our belief that close engagement with a client throughout this process is not only critical for developing a winning strategy but affords us an informational advantage that we can use to ensure that the claim and subsequent appeal are “airtight.”
Call 312-561-3010 or send us a message through our website to arrange for a consultation with one of our attorneys. At Bryant Legal Group, P.C., we will take the time to explain the ERISA appeal process and what can be done to secure the benefits that you are owed.