ERISA Claim Denials and Appeals in Colorado
If your disability, life, health, or AD&D benefits are provided through a plan established by your employer, then your claim is most likely governed by a federal law known as the Employee Retirement Income Security Act of 1974 (a.k.a.”ERISA”). If so, this federal law applies to your claim, and not the law of your state. Under ERISA, you have the right to claim disability and to present arguments and evidence to your plan administrator (either your employer or the insurance company). If the plan administrator denies your ERISA claim, you have the right to appeal the administrator’s decision. The steps you take in the ERISA appeals process will make all the difference in winning or losing your claim for benefits.
The experienced ERISA attorneys at McDermott Law have a proven track record of successfully representing clients who need to pursue their internal ERISA appeals after being denied benefits. The insurance company has not told you this: the appeal of the disability denial you have received is, by far, the most important stage of the entire process for obtaining your long-term disability benefits. You must take this step in the process very seriously. For advice specific to your case, please contact McDermott Law today.
After you receive the letter that announces your ERISA claim was denied, you must be given a reasonable chance to appeal the decision. The denial letter must clearly explain the deadline, the procedure for appealing, and must provide you with a minimum of 180 days to submit a review request.
If you fail to file your ERISA appeal in a timely manner, you will most likely have failed to comply with plan requirements; this can result in an automatic denial of your claim. If the administrator fails to make a timely decision of the appeal, the administrator will not be automatically required to pay the denied benefits. At best, the participant (you) can argue that the insurer’s failure to render a timely decision will cause a reviewing court to apply a more flexible standard of review.
If a client seeks legal help after submitting an ERISA appeal on his or her own, the client and his or her attorney should request an additional appeal opportunity — even if the denial was upheld. An additional appeal might be granted. In limited circumstances, the applicable policy may even provide the claimant with more than one appeal.
The appeal from the denial letter is the most critical stage of the entire ERISA appeals process. It is your best shot at reversing the insurer’s denial. This is because a court’s subsequent review of an ERISA-governed, long-term disability claim will be limited to the administrative record (or “claim file”) developed by the administrator-insurer. Such an administrative record is typically created long before litigation begins.
After the internal appeal is completed and a lawsuit is filed, a claimant will almost certainly be prevented from submitting additional evidence in support of the claim for benefits. Therefore, the claimant and his or her attorney must understand the importance of the pre-litigation steps that must be taken to increase the odds of success.
During the ERISA appeals process, you should take the opportunity afforded by the administrative appeal to load the claim file with as much evidence in favor of your disability as possible. Doing so will provide the plan administrator with the grounds to pay the long-term disability benefits you claimed. More importantly, this may be your only chance to submit such evidence, because it is not likely that evidence concerning disability will be accepted after the appeal has been exhausted and you have filed suit.
In the course of developing the administrative record, the claimant’s attorney should:
- Immediately request the claim file
- Request copies of the plan, the summary plan description, and a copy of the policy
- Obtain additional opinion letters from treating physicians
- Provide pertinent medical literature that better explains the nature of the disability to the claims representative (and ultimately to the judge)
- Provide documentation from co-workers, the employer, and friends and relatives concerning the claimant’s disability
- “Humanize” the record so it will document the impact of the claim on a real person’s life. These records should be submitted to the claims representative, within the appeal deadline (180 days from the denial), along with a comprehensive letter from counsel
An experienced ERISA appeals attorney is best equipped to follow these steps and build up a strong case on your behalf. If you wish to learn more about filing ERISA appeals in Colorado, please contact our ERISA appeals lawyer at McDermott Law. We can guide you through the complex procedure of filing an ERISA appeal. The claimant’s attorney must take the opportunity of the appeal to load the insurance company’s claim file with any and all favorable evidence at his or her disposal. Importantly, the rules of evidence do not apply to the information and documents submitted to the insurer as part of this appeal process. Practitioners should note that the evidence in the appeal is not only addressed to the claims manager at this stage, but also to the trial court judge, if the appeal is unsuccessful. Bias by the insurer that could be relevant might include the deliberate mischaracterization of medical evidence, mischaracterization of conversations with the claimant, an improper vocational assessment, or an improper or incomplete medical assessment. A reviewing court will likely apply a highly deferential standard of review in favor of the insurance company, requiring that a claim denial be overturned, only if the insurer’s conduct is “arbitrary or capricious.” Thus, if there is any evidence in support of such conduct, it should be submitted during the appeal.
ERISA appeals must be decided by the insurance company within 45 days. The insurer may request a 45-day extension for reasons beyond control of the plan, as long as notice is provided to the claimant.
One cannot overstate the importance of this two-step process. Unless you complete this appeal, you have no right to bring a lawsuit. More importantly, your claim and appeal had better be done well, because courts generally give significant deference to plan administrative decisions. If the plan’s administrator decides you are not entitled to ERISA disability benefits or a medical procedure, the court will uphold that decision unless it was arbitrary and capricious or an abuse of the administrator’s discretion. This standard means that if the administrator has substantial evidence supporting its denial, you cannot win — even if you have more and better evidence. So, if you do not win your ERISA appeal, you might have little chance to win in court.
Many people lose their ERISA benefits because they don’t do everything they can to prove their case during the two-step ERISA administrative appeals process.
Typically, the plan’s administrator will not help you, even though the administrator is supposedly your fiduciary. In today’s corporate environment, it is rare that plan administrators will go the extra mile to help an employee file an ERISA claim or an ERISA appeal. Instead, these “fiduciaries” sometimes go out of their way to make sure that the employee does not receive benefits. They may pretend not to receive medical records, deny claims without specifying a reason why and hope the claimant will simply give up, or even interfere with the claimant’s doctors. Some administrators will help — but, it is wise to assume that it is up to you and your attorney to prove your claim.
Hiring an experienced ERISA attorney can make all the difference in the success of your ERISA appeals process. Located in Denver, Colorado, we at McDermott Law are considered by many as the state’s foremost attorneys in this area of law.
To learn more about the terms and laws that govern ERISA litigation and appeals, please explore the following pages:
- ERISA overview and terminology
- ERISA disability/health insurance claims
- ERISA long-term disability litigation
Begin Your ERISA Appeal
If you are thinking of pursuing the ERISA appeals process, you can vastly increase your chances of success by working with a lawyer experienced in this area of the law. The ERISA appeals and litigation specialists at McDermott Law have handled literally hundreds of ERISA appeals in Colorado. We are one of the state’s foremost ERISA law firms. Contact Denver ERISA Attorneys at McDermott Law today, for an honest assessment of your case.