ERISA Claims Appeals: A Three Step Process

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Jeffrey Johnson is a legal writer with a focus on personal injury. He has worked on personal injury and sovereign immunity litigation in addition to experience in family, estate, and criminal law. He earned a J.D. from the University of Baltimore and has worked in legal offices and non-profits in Maryland, Texas, and North Carolina. He has also earned an MFA in screenwriting from Chapman Univer...

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UPDATED: Aug 5, 2019

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The ERISA (Employee Retirement Income Security Act) claims appeal process is not easy for someone who doesn’t have experience handling these types of claims. Ask anyone who’s gone through it and chances are they’ll tell you to hire an experienced attorney to handle the matter for you. However, while the process is not easy for a novice, it’s also not impossible. In fact, you may be able to go it alone if you follow three crucial steps.

Doing it yourself

We interviewed Ron Dean, a California attorney who has been practicing ERISA law for over 35 years, about the claims appeal process. Dean has seen it all over the years and while he told us that he would recommend that the appeal be done with an attorney, he says that it can be done without one. So, if you choose to do it yourself, here’s what Dean recommends you do:

  1. The first step is that you’ve got to get the relevant documents. Once you have them, you then have to read all those documents, and I mean really read them.
  2. The second step is to study the reasons for the denial in an objective way (that’s why a lawyer is helpful here).
  3. The third step is to timely file an appeal and including your new, overwhelming evidence of disability – whether it is medical or vocational.

Overcoming obstacles

Like any other claims process, you’re likely to encounter obstacles during the ERISA claims process as well. Dean provided the following advice on how to overcome those obstacles:

  • Review the evidence. There’s going to be the insurance company’s statement of how they read the evidence and the real evidence, not what they say is the evidence. So, it’s critical that you do all these things carefully. You’ve got to see what their doctors say, what they find inadequate and you’ve got go to your doctors and have your doctors address those issues.
  • Make sure your doctor explains your injury. A lot of treating doctors think it’s enough for them to say, ‘My patient is disabled. Leave them alone. He is disabled because I say he’s disabled.’ That’s not going to do it. The doctor must show the objective signs and symptoms of your disability and explain why your ‘restrictions and limitations’ (a term of art) are sufficient to establish your disability.
  • Inform your insurer about your injury. A lot of people come to me with terrible injuries or diseases, but they haven’t explained to the insurance company why that injury, disease or limitation prevents them from doing their job. The connection is critical; you absolutely have to address that. That’s where ‘restrictions and limitations’ come in.

If you’ve been denied valid benefits under ERISA, consult with an experienced ERISA attorney to discuss your situation and evaluate your options. Consultations are free, without obligation and strictly confidential.

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