The ERISA Claims Process: What You Need To Know

Filing a claim under ERISA, the Employee Retirement Income Security Act, can be quite complex. We asked Ron Dean, a California attorney who has been engaged in employee benefits litigation primarily on behalf of participants for over 30 years, to provide an overview of the process.

The process – in a nutshell

The process of filing an ERISA claim has two general components, according to Dean, who told us, “The law says that you (a) must file a claim, and (b), must exhaust the plan’s administrative processes (with minor exceptions) before you can file a lawsuit. If you file a lawsuit too early, it can be dismissed and your claim barred. If you miss the time limits for complying with the plan’s administrative processes your claim may be forever barred. If the Plan misses its time limits for responding to your claim, nothing really bad happens to it.”

However, Dean also pointed out that insurance companies have an upper hand in the process. He said, “In an ERISA claim, you don’t get a jury, you get a short hearing based on a paper record and the thumb of the law is placed heavily on the insurance company’s side of the scales of justice.”

The importance of the administrative record

As Dean said, claimants are only provided with a short hearing based on a paper record, commonly referred to as an administrative record. He explained why this record is so important:

When you go to court in an ERISA benefits case, most times the only evidence the judge will look at is the evidence you timely submitted to the insurance company before you filed your lawsuit. A plan cannot require you to go through more than two appeals, but as you can see, you want to present your strongest possible case to the insurance company. This means reading carefully every ground the insurance company gives for the denial and making sure that you answer each one.

Your response should be thorough, complete, patient, calm and objective. Remember, your appeal isn’t just for the insurance company, it’s also for the judge who just wants to get to the bottom of what the case is about.

The appeals process

Claim decisions can be appealed; however, the process isn’t exactly employee-friendly, as Dean points out:

When the plan denies your claim, it’s required to send you a letter giving the reasons for the denial and telling you what your appeal rights are and how long you have to appeal. You are entitled to have the Plan send you all of the “relevant documents” and you should immediately write to the plan asking for just that – “all the relevant documents.”

You should not tell the plan that you want to appeal until you have those documents and have collected all your evidence and are ready to present your full appeal to the plan. Make sure you present your appeal within the time limits provided by the plan, though. If you appeal too soon, the Plan will use that opportunity to promptly deny that appeal before you’ve had a chance to send them all your evidence. This may prevent you from giving them evidence to the plan or, later, to the judge.

Best practices

We asked Dean to provide some best practices on what an employee can do to make sure the claims process easier. Here’s what he recommends:

1. Obtain “all the relevant documents” from the plan;
2. Collect all your evidence;
3. Respond to every issue raised by the plan in a cool and calm manner;
4. Appeal within the time limits;
5. Present every piece of evidence that helps your claim – don’t hold anything back for “later.” This is not a time to play Perry Mason (remember him?)

If you’ve been denied valid benefits that are subject to ERISA, contact an attorney whose practice focuses in this area of the law. Consultations are free, without obligation and are strictly confidential. To contact a qualified attorney to discuss your situation, please click here. We may be able to help.

Case Studies: Filing Claims Under ERISA

Case Study 1: Denied Disability Benefits

Mary Thompson, a 45-year-old employee, suffered a severe back injury at her workplace, rendering her unable to perform her job. Seeking financial support, Mary filed a claim for disability benefits under her employer’s ERISA-governed plan. However, her claim was denied by the insurance company based on their interpretation of the plan’s eligibility criteria.

In response, Mary engaged an attorney specializing in ERISA claims to help her navigate the appeals process. Her attorney requested all relevant documents from the plan and meticulously prepared a comprehensive appeal, addressing each ground for denial. Despite the challenges posed by the process, Mary’s attorney presented a strong case that emphasized the substantial impact of her injury on her ability to work.

Case Study 2: Delayed Benefit Payments

John Davis, a 55-year-old employee, retired after a long career with a company that provided a pension plan governed by ERISA. He applied for his pension benefits as outlined in the plan, expecting timely payments to support his retirement. However, John encountered delays in receiving his benefits, causing financial strain and uncertainty.

To address this issue, John consulted an attorney with expertise in ERISA pension claims. The attorney advised him to request all relevant documents from the plan to ensure a comprehensive understanding of his case. After gathering the necessary evidence and identifying the cause of the payment delays, John’s attorney prepared a strong appeal, highlighting the plan’s failure to adhere to its own timelines and obligations.

Case Study 3: Inadequate Life Insurance Payout

Sarah Adams, a 38-year-old employee, tragically lost her husband in a fatal accident. Her husband had life insurance coverage through his employer’s ERISA plan, which was supposed to provide financial support to Sarah and their two young children. However, when Sarah filed a claim for the life insurance payout, she received an offer that fell far short of her family’s needs.

Recognizing the importance of securing adequate financial protection for her family’s future, Sarah sought the assistance of an ERISA attorney. Together, they analyzed the plan’s terms, identified potential inconsistencies, and gathered evidence to substantiate the true value of the claim. Sarah’s attorney crafted a compelling appeal, demonstrating the financial impact of her husband’s untimely passing and the plan’s failure to fulfill its obligations.