ERISA and Denied Employee Benefits Claims

While the goal of ERISA is to protect the legal rights of employees and their beneficiaries,  many of them still have difficulties recovering the benefits they are entitled to. ERISA is a complex law and it is best to consult with an experienced employee benefits attorney who can file an appeal if your claim was denied. 

A beneficiary who lost a loved one may still be going through a grieving process and may not have the strength to review complex life insurance policies and perform a thorough investigation in order to submit a comprehensive appeal brief. Further, an appeal based on the same set of documents is bound to be denied. 

When a life insurance lawyer prepares an ERISA appeal, they draft a legal brief based on ERISA law and the results of an independent investigation and research. This forces the insurance company to look at the case from a new perspective. Beneficiaries who win ERISA appeals at an administrative level save time and money that would otherwise be spent on litigation. At our ERISA law firm, we urge everyone whose benefit claim was denied to hire an ERISA counsel before filing an appeal to increase their chances of winning. 

Our Experience in Handling Denied ERISA Claims

At Kadetskaya Law Firm, we have a high success rate of recovering insurance proceeds on ERISA appeals and will make sure your ERISA appeal is handled professionally and competently.

Our ERISA lawyers have considerable experience in winning cases involving claim denials including:

  • Denial based on failure to provide a conversion application 
  • Denial based on change in marital status
  • Denial based on policy exclusions
  • Denial based on employer non-payment of premium
  • Denial based on failure to apply for waiver of premium
  • Denial based on failure to provide an evidence of insurability form
  • Denial based on employer’s mistake
  • Denial based on not being actively at work 
  • Denial based on dependent ineligibility

Here are just a few cases successfully handled by our ERISA lawyers:

In most ERISA cases, an administrative appeal is a necessary step before the claim proceeds to court. If you decide to sue your insurance company without first exhausting administrative remedies, your court action may be barred. Therefore, you need to consult an experienced ERISA attorney who will file an appeal on your behalf. Our life insurance lawyers can help you recover your wrongfully denied claim fast regardless of the reason invoked by the insurer.

How Our ERISA Attorneys Can Help Recover Your Death Benefits

At our law firm, our ERISA attorneys offer legal advice in all stages of ERISA claims. Here is what our ERISA lawyers can do to help you collect the life insurance death benefit in a timely manner: 

  • Explain how ERISA works and how to protect your life insurance beneficiary rights;
  • Assist clients with filing an ERISA claim;
  • Help clients expedite an ERISA claim delay;
  • Help clients understand the contents of the denial letter;
  • Assist clients in writing and filing an ERISA appeal;
  • Represent clients in ERISA lawsuits;
  • Represent clients whose beneficiary designation is challenged by a competing claimant’s qualified domestic relations order;
  • Represent clients in cases involving employer’s breach of fiduciary responsibility owed to ERISA claimants; 
  • Represent clients in cases involving insurers’ breach of fiduciary responsibility owed to ERISA claimants. 

When our life insurance lawyers prepare an ERISA appeal, they draft a legal brief based on ERISA law and the results of an independent investigation and research. This forces the insurance company to look at the case from a new perspective. Beneficiaries who win ERISA appeals at an administrative level save time and money that would otherwise be spent on litigation. 

At our ERISA law firm, we urge everyone whose benefit claim was denied to hire an ERISA attorney before filing an appeal to increase their chances of winning.

ERISA Attorney Fees

Our attorneys work on a contingent fee basis. It means that we do not charge legal fees unless we collect the ERISA proceeds for you. Only then will we charge a reasonable legal fee. We take pride in offering competitive contingent fee structures and will work with you to ensure you are comfortable with the fee. 

If your claim has been denied or delayed, seek legal advice from an ERISA attorney. Call (888) 510-2212 for a free case evaluation. We have the experience you can trust.

Below we will address some of the most frequent legal questions we get from beneficiaries who are in need of help with their denied or delayed ERISA claims:

ERISA Death Benefits Claims FAQ

What Is ERISA and How Does It Work?

ERISA stands for Employee Retirement Income Security Act of 1974 and is a federal law that governs all claims for benefits from an employee or group welfare benefit plan. An employee welfare benefit plan is any plan, fund, or program established or maintained by an employer or by an employee organization that provides employee benefits such as life, health, or disability. As such, if your right to benefits was through a plan established by a private sector employer or an employee organization (e.g., a labor union),  it is most likely governed by ERISA.

The purpose of ERISA is to require plans to provide participants with accurate plan information about plan features, outline fiduciary responsibilities for the plan administrator and managers, establish a complaint and appeals process for participants whose benefits have been denied, and give participants the right to sue for denied benefits and breaches of fiduciary duty.

What Plans are Covered by ERISA?

In most cases, when the employer buys life insurance for its employees, it is provided through an insurance company. If there is a plan and the plan was “established or maintained” by a private sector employer (or employee organization), it is probably covered by ERISA. 

There are two exceptions to ERISA coverage:

  • Plans sponsored by churches and church-related entities are not covered by ERISA unless an election is made to have ERISA coverage.
  • Plans established or maintained by government entities for their employees, or plans which are maintained solely to comply with workers’ compensation, unemployment, or disability laws are not covered by ERISA.

How Do I Know if My Benefit Plan Is Controlled By ERISA?

If your employer is engaged in any of the following activities, a Court will likely find that the employer “established or maintained” the Plan, mandating ERISA coverage.

  • The employer is paying all or even part of the policy premiums;
  • The employer is urging employees to join the plan;
  • The employer is retaining some of the deducted premium to administer the plan;
  • The employer is keeping track of who is in the plan;
  • The employer is answering questions for the plan members about their coverage.

ERISA Claims Procedures

Before an ERISA life insurance claim is filed, it is important to check your Summary Plan Description and Summary of Benefits and Coverage to ensure the beneficiary is eligible to receive benefits. Plans usually provide specific definitions for eligibility. For example, in some cases, a dependent can only be insured up to a certain age and stops being considered a dependent if his/her status changes. In other cases, only full-time employees who are actively at work are eligible for coverage. 

How to File an ERISA Claim?

The Summary Plan Description provided by the plan must have information on where to send your completed claim forms, what additional documents to include, and the plan’s contact information. If you decide to file an ERISA life insurance claim yourself, you may want to contact your employer/HR and request claim forms and all relevant details in filing a claim. Keeping a thorough record of your communications with the employer and the insurance company is essential in making sure you do not miss a deadline. 

If you want to make sure you file the claim and do it correctly within the required time frame, our ERISA claim lawyers can help. Call (888) 510-2212 for a free case evaluation.

What if Your ERISA Claim Is Denied?

If your life insurance ERISA claim is denied, the insurance company must send you a denial letter in writing. According to ERISA regulations, the denial letter must include the following information:

  • The reasons why your claim was denied;
  • The specific provisions in the insurance plan on which the denial is based;
  • What documents and the insurance company reviewed in deciding your claim; 
  • What additional information you need to include in your appeal for the insurance company to reconsider your original claim;
  • How to correctly submit an appeal;
  • The deadline to file an appeal; 
  • A description of your rights as an ERISA beneficiary to file a lawsuit to recover the proceeds.

If your insurance provider denies your ERISA claim, you have the right to file an ERISA appeal

One of the reasons it is best to have legal help when faced with an ERISA denial is a strict appeal deadline. Under ERISA, an adverse benefit determination (a denial) must be appealed administratively before a lawsuit can be filed. For most plans, the appeal deadline is 60 or 180 days from the date of the denial letter. It means that a beneficiary whose claim has been wrongfully denied has only 60 (or 180) days to investigate the denial, draft an appeal, prepare supporting documents, and submit the appeal before the deadline. Unfortunately, an appeal prepared without a legal brief is rarely winning. 

Another important factor to consider when dealing with an ERISA life insurance claim denial is providing an insurer with all legal arguments and documents that the beneficiary plans to include in the lawsuit. A poorly submitted ERISA appeal may restrict the beneficiary from bringing up new issues or documents during litigation.

Depending on the circumstances of your claim, insurance companies set different times to review the appeal. You might minimize the waiting time if you work with an experienced ERISA lawyer.

What Happens if Your Appeal Is Denied? 

If your appeal is denied, you have the right to bring an ERISA lawsuit. Like with appeals, filing an ERISA lawsuit is different from other types of litigation. For example, it is typically handled in federal court unless both parties agree to keep the case in state court jurisdiction; jury trials are not available and submitting new evidence might not be permitted. You can read more about the particulars of such cases in our blog post about ERISA litigation.

An experienced and knowledgeable ERISA lawyer will help you navigate the complex nature of this law to recover the life insurance payout you are rightfully entitled to.  

What Is an ERISA Attorney?

An ERISA attorney is a life insurance attorney specializing in ERISA plan operations. An ERISA lawyer makes sure plan participants are offered all the protections under the law. If a life insurance claim is wrongfully denied, an ERISA claim attorney will represent beneficiaries in their ERISA appeal and litigation to recover the denied life insurance benefits. 

When Should You Hire an ERISA Life Insurance Attorney?

You should hire a life insurance lawyer specializing in ERISA if: 

  • Your employer/insurer provided you with incorrect or misleading information about your life insurance coverage ;
  • Your employer/insurer terminated your life insurance coverage without informing you;
  • Your employer/insurer failed to advise you of your rights to your life insurance coverage if your employment terminated;
  • Your employer/insurer withdrew premiums from your paycheck for life insurance coverage that did not exist;
  • Your employer/insurer approved your evidence of insurability (statement of health)  and withdrew premiums from your paycheck for increased coverage but denied your life insurance claim after the insured’s death;
  • Your employer/insurer failed to provide you with a copy of the life insurance policy/Summary Plan Description or denied you access to plan documents regarding your life insurance benefit;
  • Your employer/insurer revoked you as a beneficiary on a life insurance policy without explanation. 

If you have issues with your ERISA claim, call (888) 510-2212 to speak with one of the ERISA claim attorneys. We offer free consultations.

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