Challenging the Denial of an Employee Benefit Claim
Appealing a denied claim
If your initial claim is denied, ERISA's detailed regulations require that the insurer or plan provide a fair and transparent appeal process, within specific timeframes. An appeal must be done before initiating litigation, or the court will not hear your case. If the insurer or plan does not follow ERISA's claims procedure rules, in some circumstances you may be able to initiate litigation before the appeal is complete. It is critical to provide the strongest appeal possible because, in the majority of cases, a court will only review what you have provided to the plan on appeal to determine if the insurer or plan has been "arbitrary and capricious" in its decision, a fairly high burden to overcome.
Crucial Deadlines for an ERISA Appeal
As the claimant, you typically have 180 days from the date of the denial to appeal the decision, however, a statute of limitations for filing a lawsuit may be shorter and run separately from the appeal timeline. It is therefore critical to consult an attorney soon after your claim is denied.
The plan administrator must decide a disability claim appeal within 45 days, with one 45-day extension if properly requested.
For health care claims, the decision time frame varies depending on the type of claim. Generally, for a pre-service claim, the response must be within 30 days, and for a post-service claim the insurer must respond within 60 days of the appeal.
For concurrent claims (an ongoing course of treatment or a number of treatments): notification of any reduction or termination of the course of treatment must be sufficiently in advance of the reduction or termination to allow the claimant to appeal and obtain a determination on review of the adverse decision before the benefit is reduced or eliminated.
For all other claims, appeals must typically be decided within 60 days of the plan's receipt of the appeal.
Like the initial denial, the insurer’s or plan’s denial on appeal must include very specific information so that you understand why your claim was denied and whether you have a strong case for litigation. In some cases you have a chance to request additional information from the insurer and make a second appeal.
The Importance of the Administrative Record in the ERISA Appeal Process
If your appeal is denied by the plan and your case is strong enough to warrant filing a lawsuit, your case will be reviewed by a judge, typically through a motion that provides the court with the record put together during the appeal process, called the administrative record. It is critical that you make the strongest appeal possible, not only to overturn the denial but also to prepare for litigation, because your case will rest on the strength of your appeal and any mistakes the plan made in processing your claim. If you have not prepared a convincing administrative record for challenging your denial, it is unlikely you will prevail in court because, typically, you cannot add documentation to your record after the appeal.
McKain Law, PLLC can help you build a strong case for your appeal during this internal review period. For example, in long-term disability cases, the firm may help you obtain an independent medical examination, collect statements from relevant medical professionals, and research and document all aspects of your claim.
Because ERISA is a federal law, you may work with an attorney anywhere in the country. While it may be seem important to have someone close to you geographically, most legal work in the area of ERISA is done remotely, because there are so few attorneys who practice in this area, particularly on the employee side. Geographic distance should not prevent you from finding the attorney best suited to build a strong case for you.