Common Tactic Used by Long-Term Disability Insurers in ERISA Claims Reveals Importance of Legal Representation

J.P. Gonzalez-Sirgo
Founder of J.P. Gonzalez-Sirgo, P.A.

This blog has explored the factual, procedural, and legal challenges that often motivate policyholders to pursue claims without the benefit of legal advice and representation.  Recent modifications to the ERISA law, which applies to long-term disability insurance coverage offered by employers, has increased the risk to claimants of attempting to proceed without an attorney.

One such change has been the tendency of courts to deny claimants the opportunity to submit responses to new information submitted by claims administrators along with their final appeal of claims.  This sharp practice directly conflicts with the “full and fair” review procedures purportedly authorized under ERISA. 

This clear strategy of sandbagging enables plan administrators to hide critical evidence and take advantage of having the last word on appeal.  This unfair approach often prevents the claimant from having ANY ability to evaluate or respond to pivotal new evidence.  Despite the incredibly underhanded nature of this tactic, judges have sanctioned the practice allowing plan administrators to decimate claimants.

Given the increasing use of this strategy, claimants have a compelling justification to obtain legal representation early in the long-term disability insurance claims process.  Because many courts are not permitting subsequent responses to new facts and contentions in a final claim denial, the paperwork constituting the original appeal must be as complete as practical to maximize a claimant’s opportunity for a successful recovery.

Many claimants have only a limited recognition of the information that comprises a complete appeal.  Claimants who attempt to submit a claim without the benefit of legal representation by an experienced attorney often submit a letter from their doctor, a demand letter, and superficial research obtained from websites.  When a complete appeal is constructed by a law firm that regularly handles ERISA claims, the paperwork can run to three or four dozen pages and include hundreds of pages of attachments.  These documents typically will include descriptions of medical conditions from medical journals/treatises, information about the insurance carrier based on past experience and research, and sound legal contentions.

A growing number of long-term disability insurance claims law firms in Florida routinely reject cases where the final denial was based on an appeal submitted by the claimant without legal assistance.  The risk of taking such claims on a contingency fee basis often is considered too high given that the claimant frequently will not be given an opportunity to even respond to the information upon which the court will hang its hat when making a decision.   

The rate of success for claimants in ERISA disability insurance claims is only about four in ten cases.  Further, these odds drop dramatically when claimants fail to file complete appeals of claims denials.    

You can reach Miami Insurance Claims Lawyer J.P. Gonzalez-Sirgo by dialing his direct number at (786) 272-5841, calling the main office at (305) 461-1095, or Toll Free at 1 (866) 71-CLAIM or email Attorney Gonzalez-Sirgo directly at [email protected].

Be the first to comment!
Post a Comment