It’s not uncommon for someone with an insurance plan covered by ERISA to have their claim denied. What’s less common is understanding how ERISA works and how you’re supposed to appeal your insurance provider’s decision when you don’t agree with it.
Despite the fact that the vast majority of Americans have insurance plans covered under ERISA (due to the fact that their plans come through their employer), precious few have any real understanding of the law. Case in point: most think that if their insurer behaves badly in denying a claim, they can take them to court and sue their metaphorical pants off. Sadly, that’s just not true with ERISA plans. The best you can hope for is to get them to pay the benefits you should have received in the first place and hopefully cover the cost of your attorney.
It’s not just the outcome that will be different, either. If you’re going to appeal a denial on an ERISA-covered plan, you need to know what steps to take.
Steps for Appealing a Denied ERISA Claim
Experienced attorneys know that there are a number of things you should do when putting together an appeal for an ERISA denial.
Review all plan documents. The plan administrator is required to give you copies of plan documents and relevant claim information within 30 days of your request.
Get the claimant’s file. Vital information can be found here and it has to be given to you as part of a “fair claims review process” under disability laws and ERISA.
Load the record during internal review. Your goal is to show that the denied claim really should have been covered based on the language in the policy, so it can be incredibly helpful to include literature in the record that supports this. The opinion of a treating physician, when written in language that mirrors the policy, is also often looked upon favorably by the court.
Pay attention to conduct. If the administrator engages in “arbitrary or capricious conduct,” this can be used to support your case. Keep a record.
Follow procedure – and watch for errors. There are specific rules the administrator has to follow. If they make mistakes, these can help you win your appeal and get benefits.
Whatever you do, make sure you work with a disability expert you trust who knows this area of the law. Don’t play games with your health. Check out our free e-book for more details about ERISA disability and be sure to stay up to date on new long term disability information through our weekly blogs!