How are administrative appeals handled under an ERISA disability insurance claim?

The Employee Retirement Income Security Act (ERISA), enacted by Congress in 1974, is a federal law which governs employee benefit plans.  Almost all employer group long term disability plans are governed by ERISA.   

Statistics show that over 70% of long term disability claims are denied.  The hiring of an experienced disability attorney is highly recommended during the appeal stage.  When your long term disability claim is denied, you usually have 180 days to appeal from the date you receive the denial letter.  You have the right to appeal the denial as per the instructions outlined in your employee benefits plan.  The appeal must be in writing and filed with the insurance company.  Usually, if your appeal is denied, you may have an opportunity to file a second and final appeal with the insurance company.  The appeal process gives you an opportunity to update your medical records.  The filing of an ERISA appeal is probably the most important step in the entire claim process.  This can be a very difficult task for an inexperienced person to undertake. 

As per ERISA, you are required to exhaust all appeals before initiating the filing of a lawsuit.  It is very important to know that a federal court may not review any additional material, including witness or physician testimony or prior medical data not previously provided, and will probably be limited to the administrative record at hand.  This is why it is important to submit a comprehensive submission of favorable data during the appeal process. 

If the filing of a lawsuit is necessary, the suit is brought in federal court with a judge deciding the outcome of the case, not a jury.  Typically, the judge reviews the administrative record, memorandums of law, pleadings submitted by lawyers on both sides and issues a summary judgment.  In addition, bad faith laws and punitive damages do not apply in ERISA claims.

The Law Firm of J.P. Gonzalez-Sirgo, P.A. represents individuals that have had their valid long term disability benefits denied, delayed or terminated irrespective of whether the policy was purchased individually or issued through an employer group policy.  The firm is available to assist individuals with the initial application process, during the administrative appeals process, handling denials of claims or termination of benefits, litigation in state or federal court, and negotiating a one-time lump sum settlement or buy-out.  Please contact our office to discuss your case in more detail.