Very few attorneys handle ERISA governed insurance claims, which is surprising since it covers almost every American in some way, shape, or form. ERISA stands for the Employee Retirement Income Security Act. This is a federal law passed by Congress in 1974. Unless you work for a governmental or church entity, then it most likely covers you. ERISA governs most employee benefits, including, short-term disability insurance, long-term disability insurance, life insurance, pensions, and health insurance.
ERISA requires employee plans to provide participants with plan information including important information about plan features and funding; provides fiduciary responsibilities for those who manage and control plan assets; requires plans to establish a grievance and appeals process for participants to get benefits from their plans; and gives participants the right to sue for benefits and breaches of fiduciary duty.
Most importantly though, it changed the way that insureds must appeal and litigate the denial of their claims, and it removed many of the state law penalties for unfair or unreasonable decisions made by insurance companies.
Unlike state law insurance claims, if your claim is governed by ERISA you must go through the insurance company appeal procedures. Unlike a state law governed insurance claim, you will not get a normal jury trial. There are a lot of traps for inexperienced attorneys or for those who think an ERISA claim is just like any other civil case.
Why should you contact an experienced ERISA attorney?
If your disability, insurance, or other ERISA governed claims are denied then it is critical to hire an attorney that knows how ERISA works to do your appeal. You must remember that under ERISA, the burden to prove that you meet the definition of disability is on you the insured. The insurance company does not have to prove the case for you. And the only opportunity to prove your case is during the claims process – either upon application or during the appeal. Once the appeal process is over, and you are forced to file a lawsuit, the claim file is mostly closed and absent extenuating circumstances you may not be able to add any information to the record. This means that the Judge will not review documents not sent to the insurance company for its review.
Think of it this way: When you open up your claim, the insurance company puts your name on a cardboard box at insurance company headquarters. Everything that you send to them goes into that box. Everything your physicians send to them goes in that box. Everything that the insurance company produces to review your claim goes into that box. If they deny your claim, then you will have 180 days to appeal.
An experienced ERISA attorney will request the claim file and review it with you. This is what we do. Then we analyze the medical facts, the insurance policy language, and what the insurance company did to review your claim. Then we put together an appeal plan to make sure that you prove your case. This could require additional testing, testimony from your physicians, or a vocational workup.
We must prove your case before the claim file is closed. Then if the insurance company denies your appeal, we will have a great cardboard box of information to show the Judge when we file a lawsuit. Simply sending an appeal letter often does not work and results in the insurance company just rubberstamping the appeal denial.
Attorney Aaron Engle has handled hundreds of disability appeals. Aaron knows how to build your case and prove to the insurance company and a Federal Judge that you have met the burden of proof. Aaron has spent his entire career helping people with ERISA and non-ERISA disability claims. He enjoys going through the medical records, reports, and insurance company arguments and then putting together a response that honors your story and shows why the insurance company made the wrong decision.
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