ERISA Denial Letters: Clues To Where The Treasure Lies

When your benefits claim is denied, you’ll get a letter stating why. This letter, according to Ron Dean, a California attorney who has been practicing ERISA (Employee Retirement Income Security Act) law for over 35 years, contains crucial information that can be used to appeal that denial. In fact, Dean says that the denial letter itself is going to give you clues as to where the treasure lies buried…

Most common reason for denial

While there can be any number of reasons for a denial, Dean says that “insufficient evidence” is one of the most common reasons. He explained:

The insurance company has its own language, but if you know how to read their language, you’ll know what kind of evidence they’re going to see as being strong enough that they can grant your claim. Claimants often see a denial that says ‘the evidence is insufficient to establish’ your disability When they say that, you’ve got to address it, hard and fast.

I know most people who apply for disability say, ‘Well, I know I’m disabled and my doctor agrees that I’m disabled. So what the heck is wrong with the insurance company and why do they say the evidence is insufficient?’ Well, the reason is because the insurance company is looking for objective evidence or substantial subjective evidence to prove the disability. Let’s face it, as human beings most of us feel the other guy’s a liar and a cheat, and unless they can show us otherwise, we’re going to presume that.

You’re presumed to be abled

Dean says that the reality is that you’re presumed to be abled unless you can prove that you’re disabled. He continued, “You’ve got to deal with it. You’ve got to present evidence. You’ve got to show a compelling case before the insurance company is willing to give you any of their money. I have a lot of clients who say, ‘Well, gee, I paid disability premiums all these years and now they’re denying me benefits?’ And they will, unless you can prove you’re disabled. Now they don’t pay it to everyone who pays premiums; they only pay it to the disabled people who pay premiums.

Three crucial parts of a denial letter

Dean says that the denial letter has three crucial parts:

1. It will give the reasons for the denial.
2. It will say you’re entitled to review all relevant documents, and that’s a term of art.
3. It will tell you that you have the right to appeal – which is usually within 180 days.

He says, “It’s at this point where the rubber meets the road. This is your chance to shine. This is your chance to prove your case and introduce new evidence.”

If you’ve been denied valid benefits under ERISA, consult with an experienced ERISA attorney to discuss your situation and evaluate your options. Consultations are free, without obligation and strictly confidential.

Case Studies: ERISA Denial Letters

Case Study 1: Addressing Insufficient Evidence

Amy filed a disability claim under an ERISA-governed insurance policy, believing that her medical condition qualified her for benefits. However, she received a denial letter stating that the evidence provided was insufficient to establish her disability. Perceiving the discrepancy between her doctor’s diagnosis and the insurer’s decision, Amy sought the expertise of an ERISA attorney.

The attorney reviewed the denial letter, identified the insurer’s requirement for objective or substantial subjective evidence, and guided Amy in gathering and presenting compelling evidence to support her claim.

Case Study 2: Proving Disability and Overcoming Presumption

Mark applied for long-term disability benefits under an ERISA-covered plan. Despite his consistent payments of premiums, he faced a denial based on the insurer’s presumption of his ability to work. The denial letter indicated that Mark needed to present evidence proving his disability to qualify for benefits. Realizing the uphill battle ahead, Mark engaged an experienced ERISA attorney to navigate the complex process.

The attorney strategized Mark’s case, collected additional medical records and expert opinions, and crafted a strong appeal to counter the insurer’s presumption and demonstrate his disabling condition.

Case Study 3: Seizing the Opportunity in the Denial Letter

Jennifer received a denial letter for her ERISA life insurance claim, citing inadequate documentation and information. Instead of feeling discouraged, she recognized the denial letter as an opportunity to strengthen her case. Jennifer sought the assistance of an ERISA attorney, who carefully analyzed the denial letter’s crucial parts.

Together, they identified the gaps in the initial claim submission, gathered missing documents and relevant information, and prepared a comprehensive appeal that addressed the insurer’s concerns and provided compelling evidence for her claim.