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What is ERISA and How Does It Work
The Employment Retirement Income Security Act is a federal law that oversees the management and distribution of many types of employee benefits, including insurance provided by employers for short and long-term disability. If you work for a company, it’s crucial to determine if your disability policy is governed by ERISA, which could dramatically affect your claim.
Experienced disability lawyers in Florida explain that definite yet complex rules govern ERISA-based policies. The rules ensure that employees’ benefits are protected and that administrators act in the best interests of the insured workers. Navigating the system when pursuing a claim can be challenging, but legal experts can help.
What Are the Common Reasons Why ERISA Claims Are Sometimes Denied?
ERISA claims are often denied or terminated. Florida ERISA disability claim attorneys highlight the following as the most common reasons why your claim could be denied:
Incomplete or Inaccurate Information on Your Application for Disability Benefits
Your ERISA claim can be denied if you submit inaccurate or incomplete information. Florida ERISA disability attorneys can review your application for your benefits to ensure you provide all the required documents and forms. Your medical records should be accurate and provide proof of eligibility and other supporting evidence.
Not Meeting Eligibility Requirements
Each policy or plan under ERISA has specific eligibility criteria you must meet to qualify for the benefits. For example, a plan may stipulate the minimum hours you must work or the waiting period before benefits commence. Your claim may be denied if you don’t meet these criteria.
The issue is common with disability claims. You may assume you’re covered but don’t meet the requirements. Ensure you thoroughly evaluate your ERISA-based disability plan to determine your eligibility before you stop working. Skilled disability lawyers can help.
Lack of Reasonable and Appropriate Medical Treatment
Another reason for denial would be if the insurer believes that you are not getting reasonable and appropriate medical care. They often require that you get medical care on a regular basis and from a specialist. If your claim was denied or benefits were terminated on this basis, seek the intervention of skilled individual disability claims attorneys in Florida for legal guidance.
Pre-Existing Conditions
Some disability policies or plans can exclude coverage if you have a pre-existing condition for which you got treatment during the look-back period. That means that if you got treatment or treatment was recommended during the look-back period, the insurer or plan may not consider those medical conditions as the basis of your claim. For example, if you had treatment for a back condition during the look-back period and then claim you are disabled as a result of that back condition, your claim will be denied.
Not Following Proper Procedure
It’s common for ERISA policies or plans to have strict procedures and timelines for filing and appealing the denial of claims or the termination of benefits. Not meeting the deadlines or following the necessary steps for appeal can lead to the automatic denial of your claim and an inability to sue in federal court..
How Does the ERISA Claim Process Work?
ERISA is supposed to provide a fair process to resolve disputes over unpaid disability benefits, but that is not always the case. If your disability claim has been denied, skilled Florida individual disability claims lawyers can help you overturn the decision to refuse to give you the benefits.
They can help you file an ERISA claim to resolve the issue through the following steps:
- Review the denial letter to determine the reasons for the outcome, which will enable you to create a solid strategy. Then, check the letter for the appeal process, including deadlines and required documentation.
- You must file an appeal to the denial within 180 days of getting the denial letter. The deadline is strict, so it would help to hire skilled lawyers with experience in ERISA claims.
- The insurer will review your appeal in 45 days, but they can extend the period by another 45 days.
- If you lose the appeal, your lawyers can help you bring a lawsuit in federal district court. A judge, not a jury, will hear the case.
- Your case will be determined based on the legal briefs presented by both parties and the insurance company or plan’s claim file. You will not have a chance to testify or present witnesses. The judge will decide based on the record submitted during the appeal before filing the suit.
- The judge can give the insurer or plan deference when reviewing the denied claims. Based on the available information, the court can overturn the insurer’s decision if it is unreasonable or arbitrary.
ERISA rules and case law can significantly limit the scope of discovery during litigation. The parties involved can only request information from the other side to a specific extent. Consider getting the representation of experienced lawyers to enhance the appeal process and increase the likelihood of a favorable outcome.
A Skilled Disability Attorney Helping You Navigate ERISA Claims
Navigating the ERISA claims process can be lengthy and complex if your disability claims have been denied. Unlike other lawsuits, the discovery process is limited, reducing your chances of successful litigation. However, don’t give up the fight for your rights, as skilled Florida ERISA disability claims attorneys can walk the journey with you.
The Florida disability attorneys at The Law Office of Nancy L. Cavey are dedicated to seeing clients win. We can help you enter new evidence at the appeals stage to enhance your chances of a favorable outcome. Let us evaluate your case specifics and create a solid strategy to help you file a claim against the carrier or plan. Call us at 727-477-3263 for a FREE consultation.
