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Winning ERISA LTD Appeals

Winning ERISA LTD AppealsIf a long-term disability (LTD) insurance provider subject to the Employee Retirement Income Security Act, or ERISA, has denied part or all of your claim for disability benefits, you do not have to take “no” for an answer. You have the right to timely and comprehensively appeal the claim denial so that you receive the insurance benefits you need and deserve.

Let’s take a look at how an experienced long-term disability claims attorney at DarrasLaw assists people in your position by filing an administrative appeal of a wrongful claim denial claim under an LTD policy governed by ERISA.

About LTD Benefits and Administrative Appeals

Many employers purchase LTD insurance for their employees as a work related employment benefit, to protect them against the financial impacts of disability that keeps them from working and earning an income.

LTD coverage is not the same as workers’ compensation insurance. Workers’ comp protects workers against injuries and sickness while on the job. LTD, by comparison, covers employees against disabilities because of accidents or illnesses that have nothing to do with their employment.

A group LTD policy offered by an employer must comply with the provisions of ERISA in how the insurance company manages and implements it. One of ERISA’s most important provisions when it comes to LTD insurance is that employees who file a valid claim and receive a wrongful denial have the right to file an administrative appeal. An effective administrative appeal can reverse a wrongful claim denial, and result in the employee receiving important past due LTD benefits.

(We pause here to point out that ERISA guarantees administrative appeal rights only for denials of claims under employer-provided or other group LTD insurance policies. Many people buy their own individual private insurance coverage from an agent or broker. AFLAC, with the talking duck commercials sells these individually purchased policies, for example. ERISA requirements do not generally apply to individual policies, which means that administrative appeal rights may differ from what ERISA requires of group plans, or may not exist at all. An experienced individual and LTD claims lawyer can help you with these types of policies.)

Timing Is Everything

Under ERISA, the company that administers an employer-provided LTD group policy administrator must give a detailed explanation for any claim denial. That denial should point to any policy language the decision relied on, it should advise the claimant (you) of your right to obtain a copy of your administrative record, and it should explain your administrative appeal rights. Any failure of a claim denial to provide this information could constitute a violation of applicable federal laws or ERISA regulations.

ERISA also generally guarantees you at least 180 days from the date of the claim denial to file an administrative appeal. Believe it or not, that is not a lot of time. In order to prepare an effective administrative appeal, you and your group long-term disability lawyer may well need every minute of those 180 days.

Group LTD policies governed by ERISA may offer multiple levels of administrative appeal. The law only expressly gives you a 180 day administrative appeal window for the first level, however. If you have the right under your policy to an administrative appeal of the denial of your first appeal, and so on, the law only requires that the policy gives you a reasonable amount of time. Some group insurers treat that period as 180 days, but not always, so it pays to take care and consult an experienced ERISA lawyer.

Once you have filed your comprehensive, timely administrative appeal, the administrator has just 45 days to review it and to answer your arguments for overturning the denial decision.

By the same token, if you miss this strict and unforgiving deadline, you may have committed a fatal claim error and risk losing all of your disability claim rights. It is critically important to comply with all deadlines for the administrative appeal of any wrongful denial of a claim under an ERISA LTD policy.

Only File Administrative Appeals of Substance

LTD plan administrators may try to make filing an administrative appeal seem simple and straightforward. Do not let them lull you into a false sense of security that merely saying “I appeal your denial,” will suffice. After meeting deadlines, the most important part of an administrative appeal is submitting a thorough, detailed initial administrative appeal filing supported by complete and convincing medical, financial, occupational and legal evidence.

You only get one shot at your administrative appeal, because whatever is left out generally can’t be added to your record, so you must never leave out important arguments, information, or documentation, such as:

  • Copies of all correspondence relating to the claim; summaries of pertinent phone calls or field visits
  • Arguments that respond to every reason the LTD insurer gave for the claim denial;
  • Supporting documentation, especially relevant medical, occupational, financial, vocational and employment records;
  • Statements and chart notes from all of your qualified treating medical professionals describing your disability and answering any dispute the claim denial raised about it; along with restrictions, medication and side effects, chart notes, x-rays, MRI’s, EMG, NCV and CT scans.
  • Citations to current laws, regulations, court decisions, and LTD policy language from the jurisdiction you live in.
  • Procedural objections you want to raise about how your long term disability insurance company improperly handled your claim.

Not every effective ERISA LTD administrative appeal submission will contain equal amounts of all of this information. Still, no matter what the particulars of your case, you must always file a comprehensive and well-argued administrative appeal. You will not get a second shot at it. Should you need to go to court, a federal ERISA judge will decide your case based on what you submitted in your initial claim application and your administrative appeal. You may not introduce new evidence, call or cross-examine witnesses, demand a jury trial, or exercise any of the other rights that you might enjoy in other legal cases.

Trust a Top-rated ERISA LTD Claims Attorney to Handle Your Administrative Appeal

In case the descriptions of the administrative appeal above haven’t made it clear, we want to emphasize that it takes experience and specific know-how to prepare and pursue an effective administrative appeal of a wrongful claim denial under an ERISA LTD policy. Do not fall for the plan administrator’s assurances that you can go the administrative appeal process on your own—speak with a top-rated long-term disability lawyer first. The administrative appeal constitutes a critically important step. You are more or less stuck with what you file at that time, so you must get it right the first time.

With every moment that goes by, the task of effectively filing an administrative appeal becomes harder. The sooner you contact an experienced ERISA LTD claims attorney, such as our Los Angeles ERISA lawyer, the better your chances of submitting the strongest-possible administrative appeal and reversing the wrongful claim denial. That is why our strongest advice to you, if you have received a bad faith claim denial under your employer-provided LTD policy, is to contact an experienced LTD claims attorney immediately. Do not wait another second before you contact an ERISA lawyer.

DarrasLaw is Americas' most honored and decorated disability litigation firm in the country. Mr. Darras has seen more, evaluated more, litigated more, and resolved more individual and group long term disability and long-term care cases than any other lawyer in the United States.

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