ERISA Denial Letters: Clues To Where The Treasure Lies

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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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Written by Jeffrey Johnson
Insurance Lawyer Jeffrey Johnson

UPDATED: Aug 5, 2019

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When your benefits claim is denied, you’ll get a letter stating why. This letter, according to Ron Dean, a California attorney who has been practicing ERISA (Employee Retirement Income Security Act) law for over 35 years, contains crucial information that can be used to appeal that denial. In fact, Dean says that the denial letter itself is going to give you clues as to where the treasure lies buried…

Most common reason for denial

While there can be any number of reasons for a denial, Dean says that “insufficient evidence” is one of the most common reasons. He explained:

The insurance company has its own language, but if you know how to read their language, you’ll know what kind of evidence they’re going to see as being strong enough that they can grant your claim. Claimants often see a denial that says ‘the evidence is insufficient to establish’ your disability When they say that, you’ve got to address it, hard and fast.

I know most people who apply for disability say, ‘Well, I know I’m disabled and my doctor agrees that I’m disabled. So what the heck is wrong with the insurance company and why do they say the evidence is insufficient?’ Well, the reason is because the insurance company is looking for objective evidence or substantial subjective evidence to prove the disability. Let’s face it, as human beings most of us feel the other guy’s a liar and a cheat, and unless they can show us otherwise, we’re going to presume that.

You’re presumed to be abled

Dean says that the reality is that you’re presumed to be abled unless you can prove that you’re disabled. He continued, “You’ve got to deal with it. You’ve got to present evidence. You’ve got to show a compelling case before the insurance company is willing to give you any of their money. I have a lot of clients who say, ‘Well, gee, I paid disability premiums all these years and now they’re denying me benefits?’ And they will, unless you can prove you’re disabled. Now they don’t pay it to everyone who pays premiums; they only pay it to the disabled people who pay premiums.

Three crucial parts of a denial letter

Dean says that the denial letter has three crucial parts:

  1. It will give the reasons for the denial.
  2. It will say you’re entitled to review all relevant documents, and that’s a term of art.
  3. It will tell you that you have the right to appeal – which is usually within 180 days.

He says, “It’s at this point where the rubber meets the road. This is your chance to shine. This is your chance to prove your case and introduce new evidence.”

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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