Appealing ERISA Disability Insurance Claim Denials

The process for appealing a disability plan regulated by the Employee Retirement Income Security Act of 1974 (ERISA) is different than disputing an individual disability insurance denial.  You do have the right to sue on a denied disability insurance claim, but you need to follow the internal administrative appeal process established by the insurance company first.  If you fail to pursue the internal appeal process, it can significantly impact your lawsuit.

There are basically two steps in handling ERISA disability insurance claims, which include the initial filing of your claim and review by the insurer.  If you are denied disability insurance benefits you are given two options, either you can accept the decision or you can appeal for another internal review within the insurance company.  Each step has deadlines that are specified in your policy and denial letter.  If you do not adhere to these deadlines, you may lose your ability to appeal the decision and file a lawsuit.

It is important to properly prepare for the appeal process as you only have one chance to make your case.  You are also not allowed to add evidence after the appeal process is completed.   To help your case, you need to ensure that you thoroughly prepare your argument and make sure you have your file assembled correctly.

If your disability insurance claim is denied, you will receive a denial letter from the claims reviewer.  In the denial letter, the insurer must provide the reason for denial, reference the specific policy provision used to make the decision, explain the process to have the denied claim reviewed and advise you on your legal rights to file a lawsuit under ERISA.  In addition, the claims reviewer must either provide or offer to provide any internal rules or other criteria used to make the claims decision.

As you prepare your file for review, include as much information as possible that proves your case and shows how the disability has impacted you.  Also, give a rebuttal for each reason listed in the denial letter, by providing relevant evidence.  Once you submit your appeal, the appeals committee is required to give your file an extensive and fair review.  You should receive the decision in writing within 45 days of filing.

If you are not satisfied with the results of your disability insurance appeal, you can pursue a lawsuit under ERISA.  An experienced disability insurance claims attorney can help prepare your case for court.

Contact J.P. Gonzalez-Sirgo at 305-461-1095 in Miami Dade County or toll free at 866-71-CLAIM.  He can also help you with the complex disability insurance appeals process.