You are sick, injured and cannot work. Your doctors are doing all they can to help you and advise you that you cannot work and place restrictions and limitations on your activities. You submit a claim for your long-term disability benefits and a short time later you receive a letter in the mail stating that your claim has been denied and that the insurance company thinks you can go back to work. Now what do you do?
If your claim arises from a group plan available through work, your claim is governed by a federal statute called ERISA (Employment Retirement Income Security Act). If you have been denied disability benefits under a group plan, you are entitled to a "full and fair" appeal. This allows you the opportunity to submit documents in support of your claim. Failure to submit a timely appeal can jeopardize your ability to pursue you claim. If your claim is denied on appeal, then you can file a lawsuit against the claim administrator in federal court.
Unlike what you may have seen on TV or experienced in another legal claim, an ERISA claim proceeds by different rules if the case enters the federal court system. There usually is no discovery, no depositions, and there is never a jury trial. The court's review of your claim will be limited to the administrative record (the insurance company's file). Therefore, the appeal stage is your one chance to do everything you can to support your claim by submitting all the information that you believe supports the limitations and restrictions that prevent you from being able to work. Everything you send to the insurance company as part of your appeal becomes part of the "administrative record."
The law requires that you submit a timely appeal otherwise you will have failed to exhaust your administrative remedies. If you fail to exhaust your appeal rights, you will not be permitted by law to pursue a legal case against the claim administrator (it is usually the insurance company that insures the Plan).
Although not required, you should hire a lawyer with experience in handling ERISA disability claims to help prepare and submit your appeal. With our firm's help, we will help get a complete copy of the administrative record and prepare an appeal that provides you the best opportunity of getting your claim reinstated. Even if the appeal is denied, it is important to develop the record as best as can be with the information available in order to give you the best chance of prevailing in litigation if your case proceeds to federal court. We will work with your doctors to get the complete support your need for your case.
After the claim administrator has made a final decision to deny your claim on appeal, you will not be able to add additional information to the administrative record, except under very limited circumstances. Think of it as a door closing behind you when the claim administrator makes a final denial on appeal. When that door closes, you will not be able to go back inside.
Todd Krauss & Associates specializes on ERISA litigation and is ready to help you attain the benefits that you paid premiums to have in order to protect your income in the event that you become unable to work. Call today for a free consultation.