The Employee Retirement Income Security Act of 1974 (ERISA) governs employee benefit plans such as pensions, health, severance, life and AD&D plans. ERISA allows plan participants and beneficiaries who are denied benefits, a means to file a legal action to recover disputed benefits in either state or federal court after they exhaust administrative remedies for reconsideration under the terms of their Plan.
The Administrative Process for Appeals
When a disability claim is denied, the plans claim administrator should provide the basis for claim denial so the claimant can respond via an appeal. Keep in mind there are established deadlines set forth by Department of Labor (DOL) for the submission of an administrative appeal. If a claimant misses the deadline, they may lose the right to have their claim reconsidered.
To evaluate a denied benefits claim, a claimant’s attorney will obtain the administrative record (aka claim file) and the governing plan documents that set forth the eligibility and requirements for payment of benefits. Requests for documentation will be directed to plan administrator who sponsors the benefit plan and the claims administrator who funds the benefit and makes eligibility determinations.
Once the claimant’s attorney evaluates the denied benefits claim and the plan documents, they will perfect the claim and appeal, typically providing additional information to the administrator to support the disability claim. Disability claims are often denied for three reasons:
- no objective evidence of diagnosis
- no objective evidence of disability
- no vocational causation between diagnosis, disability and the claimant’s inability to perform the duties of their occupation
If all possible appeals are denied, marking the end of the administrative process, the case may go to court. Judicial review is often limited to the contents of the established record, so it is critical that the claimant or their attorney include all available evidence supporting the benefits claim during the administrative process.
Contact a Disability Benefits Denial Attorney for Help
When you have been denied disability benefits, it is important to discuss your situation with an experienced employment law attorney promptly, allowing him or her to prepare an appeal and file it before the deadline. If you already filed an appeal, it may be possible to withdraw your appeal to add information to strengthen you claim; or, if your appeal was denied, it may be possible to appeal a second time. If you were not properly advised of your appeal rights and the time has lapsed to file, litigation may still be an option. Your disability benfits attorney can review your case to determine the best course of action. Contact the employment law offices of Alan C. Olson & Associates for guidance at 262-785-9606.
