ERISA Claims
The Law Offices of Kevin M. Zietz provide effective representation and advocacy for people who have been denied disability, life and long-term care benefits under group plans sponsored by one’s employer. If a person has been denied benefits under a group plan, it is important to consult with an attorney experienced in handling denied claims that are governed by a federal statute called ERISA (Employee Retirement Income Security Act of 1974).
What Does ERISA Cover?
ERISA covers almost all employee benefits that a person may have at their job, including:
- 401K plans;
- Long term disability plans;
- Most short term disability plans;
- Health insurance plans;
- Dental plans;
- Life insurance plans;
- Long term care plans;
- Severance plans.
The only employee benefit plans not covered by ERISA are:
- Certain stock option plans;
- Top hat plans;
- Governmental plans;
- Church plans; and
- Plans established to comply with workers compensation, unemployment, and short term disability laws.
The plans identified by the five bullet points above remain subject to State law.
Law Offices of Kevin M. Zietz helps clients with denied disability, life, and long-term care claims governed by ERISA. Law Offices of Kevin M. Zietz helps clients at the administrative appeal stage all the way through a trial in federal district court if litigation becomes necessary.
When a person is initially denied benefits under a group plan governed by ERISA, it is important to understand that the denial letter is required to explain the claim administrator’s reason for denying the claim. The denial letter will also inform the claimant how long they have to submit a request for appeal. A person denied benefits under a group plan governed by ERISA has at least 180 days from receipt of the denial letter to submit a request for appeal. Failure to submit a timely appeal can result in a person being barred from pursuing their claim any further. Therefore, it is important to consult with a lawyer who is experienced in handling claims governed by ERISA to make sure that the appeal is handled in a timely manner.
Why Do I Need to Appeal a Denied Claim Governed by ERISA?
The law requires that a person with a denied ERISA claim exhaust their “administrative remedies” before they move forward with a lawsuit against the claim administrator and/or the group plan. This means that a person is required to exhaust the appeal process (i.e., their administrative remedies) before they can legally move forward with their claim. If a person were to file a lawsuit against the claim administrator and/or group plan without exhausting their administrative remedies, a federal court would dismiss the case.
Why is the Appeal Process Important?
In order to understand why the administrative appeal process is important, it is necessary to understand how claims governed by ERISA are adjudicated in the federal court system. Unlike your typical television legal case where the parties are shown arguing their case to a jury, there is no right to a jury trial in ERISA actions seeking monetary damages. The Seventh Amendment right to a jury trial in civil matters does not exist on claims governed by ERISA. A lawsuit alleging the wrongful denial of benefits will be reviewed by a federal district court judge on the “administrative record.”
The “administrative record” is the legal term that describes the file developed by the claim administrator during the handling of a claim. Generally speaking, a federal court judge will only be allowed to consider the information that exists in the claim administrator’s file as of the time of a final denial following a review on appeal. If relevant and persuasive evidence is not presented to the claim administrator when the claim is initially presented to the claim administrator (i.e., during the application process), or during the administrative appeal process, that information will generally be inadmissible at the time of trial.
A person with a denied ERISA claim has an opportunity to “throw the kitchen sink” at the claim administrator (usually the insurance company) during the administrative appeal process. There is usually no testimony from witnesses at the time of trial. The claimant will not testify at trial, nor will any of the claimant’s treating doctors. Likewise, nobody from the claim administrator will testify in court at the time of trial. Therefore, administrative appeals should be handled carefully and skillfully in order to give the claimant the best chance of being successful in getting a denial of benefits overturned on appeal. Even if the denial of benefits is not overturned on appeal, the appeal process can be used to make the “administrative record” as strong as possible so as to give the claimant the best chance of being successful in federal court.
How Long Do I Have to Submit an Appeal?
Every employee benefit plan is required to establish and maintain a procedure by which a claimant has a reasonable opportunity to appeal an adverse benefit determination. The law provides at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination (29 CFR § 2560.503-1 (h)(3)(i)). Check the Summary Plan Description (SPD) to see if the plan prescribes a longer time to submit a request for appeal. It is always a good idea to speak with a lawyer with experience handling ERISA claims after receiving a denial letter on a claim governed by ERISA. Some group plans have a multiple tier appeal process, so it is important to make sure that the claimant has exhausted their administrative remedies. Also, it is important to understand how the appeal process works, and to discuss a strategy that provides for the best chance of being successful on appeal.
What Happens if a Claim is Denied on Appeal?
Once the claim administrator issues its final decision on appeal, a person has officially exhausted their administrative remedies. That means they can file a lawsuit in a federal district court.
If a person handles an ERISA claim on their own through the administrative appeal process, and now has a final denial letter in their hands, they should consult with an attorney with experience handling lawsuits in federal district court involving denied benefits. The rules that apply to these cases in federal court, and the process for preparing an ERISA case or trial, can be a trap for the unwary.
Law Offices of Kevin M. Zietz provides a free consultation and will review a person’s denial letter and discuss the case at no expense to the potential client. Call for your free consultations today!
