ERISA CLAIMS

ERISA, a federal statute, stands for the Employee Retirement Income Security Act of 1974. ERISA governs disability insurance claims that are made pursuant to a group employer plan, unless such plan is administered by a government or church employer, such as a public school or church-run hospital. Thus, if you are claiming disability benefits through your employer’s disability plan, your claim most probably comes under ERISA.

ERISA is NOT a claimant-friendly law. Throughout the claim process, even before getting into litigation, one must be well-informed, as ERISA presents many pitfalls that can weaken your claim or even prevent you from filing a lawsuit.

For example, in most cases a claimant cannot submit any medical evidence after the date the insurance company issues its final denial. Also, failing to appeal a denial to the insurance company in a timely manner will disallow a future lawsuit.

In addition, most claim denials are governed by an “arbitrary and capricious” standard of review, which directs courts to uphold benefit denials even if the insurance carrier was wrong, as long as they were “reasonable”. Such carriers are often deemed reasonable by the courts as long as their medical consultant concluded that the claimant could work.

With all of this in mind, an ERISA claimant must build the strongest case possible by properly documenting her illness and functionality, as well as refuting the insurance company’s characterization of the claim, i.e. the alleged “lack of objective evidence” and the perceived ability to return to work, so that even with this harsh law, the claimant is in a position of leverage.