ERISA is The Employee Retirement Income Security Act of 1974. ERISA sets up minimum standards for such welfare benefit plans as life insurance, disability insurance, retirement, and health. The ERISA protections only apply to non-government employers that offer employer-sponsored life insurance coverage to employees. If your claim has been denied, the first question to ask is whether the insurance policy was a privately purchased individual insurance policy. If it was, ERISA laws will not apply.
ERISA regulates the conduct of insurance companies. Generally, it places a fiduciary duty upon insurers and employers as plan administrators. Under ERISA, plan administrators are required to perform their duties to the highest degree of responsibility. ERISA regulates reporting and accountability, disclosures, procedural safeguards and financial interests of plan participants. For example, an insurer must provide such disclosures as the plan summary which shows what benefits the plan offers, the plan’s limitations, and guidelines for obtaining benefits such as filing a claim, appealing an adverse decision and filing a lawsuit.
If a life insurance claim is denied, ERISA mandates that a written appeal is filed before the beneficiary can file a lawsuit in court. The administrative appeal is usually reviewed by an independent examiner who had not worked on the initial claim determination. Since there is only one chance to appeal a denial of a life insurance claim and strict deadlines apply, it is critical to retain an ERISA attorney to help in this complex process. An ERISA life insurance lawyer will help you file a successful administrative appeal within the deadline. A life insurance attorney will know what facts to look for during the pre-appeal investigation. In addition, with the help of legal counsel experienced in ERISA appeals, your appeal may include may several claims, new evidence and a comprehensive explanation of your legal position. Only an attorney can research ERISA cases all across the country and in the insured’s circuit and cite them in the appeal. A do-it-yourself appeal is not advisable due to lack of legal research and case law citations.
What Should I do if my ERISA Life Insurance Claim Been Denied?
If your claim has been denied, you need to know that you have legal rights and restriction. ERISA not only gives plan participants a lot of rights, but it also places a lot of limitations on filing a lawsuit. Thus, as a beneficiary of an ERISA plan, you may:
- File a lawsuit in federal court if the appeal is denied;
- Appeal the denial of benefits;
- Sue an insurance company for breach of fiduciary duty;
- Present new evidence during appeal;
At the same time, a policyholder may not:
- Sue an insurance company for breach of contract or bad faith
- Admit new evidence in a trial against the insurance company (if it was not introduced during appeal);
- Have a jury trial;
- Be entitled to conduct any pre-trial discovery.
Do I Need an ERISA Life Insurance Lawyer?
An ERISA claim appeal must be done in writing. The appeal process is by far the most important step in any ERISA controlled claim. Appeals are legally required as a necessary administrative remedy and a prerequisite to filing a lawsuit. If a person does not appeal in a timely fashion, the person will be barred from pursuing his/her claim. Further, the appeal is generally the last chance to offer evidence to the record. It is important because generally when a lawsuit is instituted the insured or his or her attorney will not be allowed to submit new information at that stage. Thus, an experienced attorney will know how to collect the documents from the insurance company and other sources that must be reviewed to properly handle the appeal and will know how to communicate with the insurance company during this process to make sure that the insured’s rights are best protected.
When Can I file an ERISA life insurance lawsuit?
As there is no statute of limitations SOL under ERISA, the plan specifies when a lawsuit can be initiated. Unless the term is extremely short, the court typically upholds the plan’s SOL. Know that the administrative review process needs to be exhausted before a lawsuit can be filed. Know that our ERISA life insurance lawyers will explain to you how we will win your claim.
My group life insurance claim was denied, what do I do?
Many group life insurance policies are controlled by ERISA. Know that ERISA trumps state law, and you need an experienced ERISA lawyer, one with at least fifteen years experience.
Why was my group life insurance claim denied?
Insurance companies typically try to avoid paying these claims by maintaining that there was a misrepresentation of the application. They also love to claim that the insured was ineligible because of a delay of the start date. Other reasons include denial for failing to apply for portability coverage; denial because of disability of a dependent; denial for failing to meet requirements of eligibility. Also, group life insurance claims may be denied due to failing to provide a form of insurability.
Group life insurance companies will try to deny the claim if the deceased was on sick leave, or was on vacation when he or she died. The carrier may claim that the deceased was not a full-time employee, and that he didn’t work sufficient hours. They love to claim that the deceased was not an active employee. Issues of divorce cutting off rights to benefits may be claimed, but if the policy falls under ERISA, Federal law will trump the state law.
Life Insurance Claims Under ERISA
Many people obtain life insurance through their employer. Employers often offer life insurance as part of an employee benefit package that may contain basic life insurance and accidental death and dismemberment coverage. Unless your employer is a governmental agency or a church, most likely the life insurance plan is governed not by the law of the state where you live, but by federal law which controls all other employee welfare plans. This law is called ERISA.
ERISA offers a lot of protections to life insurance plan participants: insureds and beneficiaries. It imposes a fiduciary duty of loyalty on the plan administrator and requires it to administer claims in the best interests of its participants. When an insurance company denies an ERISA life insurance claim, the beneficiary can sue not only for breach of contract claims, but also for breach of fiduciary duty and equitable estoppel.
What every beneficiary needs to know is that ERISA is a very complex statute. In order to win an appeal of your denied life insurance claim, you need not just a life insurance attorney, but you need an experienced ERISA life insurance attorney. Because the federal law controls such claims, the attorney you hire needs to be an ERISA expert, or, in other words, know his way around ERISA administrative appeals and federal court litigation.
At our firm, our ERISA life insurance attorneys have worked hard to earn their reputation as some of the best ERISA attorneys in the country. We have helped many beneficiaries recover proceeds under an employer-based life insurance plan. We know what it takes to reverse a denial on administrative appeal. Under ERISA, if your claim for life insurance benefits was denied, you have only 60 days to file an administrative appeal. In addition, you are limited to one appeal. If you lose the appeal, your next step is to file a lawsuit in a federal court.
Many people try to file an administrative appeal on their own, without seeking legal help. They make a mistake by thinking that a simple letter to the insurance company stating that they disagree with the denial will suffice. Unfortunately, it almost never does. To file an appeal under ERISA, you need to follow certain rules and know the federal, state and circuit law. It is not an easy task to draft an ERISA appeal for someone with no experience in such cases. Many beneficiaries have called us seeking help after their appeal was denied. Remember, that your chances to recover life insurance money are much greater if your ERISA attorney files the appeal.
Similarly, if your attorney does not have experience with ERISA appeals, it may undermine your chances of having the denial reversed. Call us now for a free consultation.
Often an employer contracts with an outside insurance company to provide group life insurance benefits to its employees. In many cases, such insurance contracts are controlled by ERISA, a federal law which controls employee welfare benefit plans. ERISA plans provide many protections for the participants. When the insurance company denies your initial claim for benefits under a disability, retirement or life insurance policy in an effort to lower costs or increase profit, call us for a free consultation about your rights.
When your initial claim for an ERISA-covered benefit is denied, you can appeal to the plan administrator. If the denial is not reversed on appeal, you can file a lawsuit in federal court. An ERISA plan usually has specific language about appeals and how they should be handled. This can be a complex process, requiring detailed attention to documentation requested by the plan administrator. At our law firm, our life insurance attorneys have years of experience helping people appeal denials of their initial claims for benefits.
Appealing a Denied ERISA Claim? Call Us For Help!
We strive to make sure that the appeal submitted is thorough and includes all relevant documentation. It is very important to be complete at this initial stage of the appeal process, as it may be impossible to add new documentation if your appeal is denied and the case then proceeds to federal court. In addition to obtaining complete medical records from doctors and hospitals, your ERISA attorney will prepare and file affidavits, witness statements and expert opinions necessary to reverse the denial of benefits. If your ERISA claim has been denied, call us for a free consultation. We offer a wide variety of legal services including filing administrative appeals and ERISA litigation. We do not charge a fee unless we win your case.