A History Of Success In ERISA Claims Matters
Attorney Reagan Toledano

The connection between an ERISA appeal and litigation

On Behalf of | Oct 5, 2024 | ERISA Process And Procedures

Many successful professionals have insurance coverage that they may never use. Those in well-compensated professions often have employer-sponsored benefits that may include short-term and long-term disability insurance.

Those benefits help supplement available Social Security benefits and any private coverage the workers carry on their own behalf. The vast majority of professionals never require disability benefits because they never experience a debilitating medical issue that prevents them from working. However, disability coverage exists for a reason. People never know when they might contract a severe illness, get diagnosed with cancer or sustain life-altering injuries in a car crash.

Those with debilitating medical challenges may file a claim seeking long-term or short-term disability benefits. In some cases, they may have a long path to travel before they obtain those benefits. They may need to appeal and might even need to file a lawsuit. What happens during the appeals process influences whether or worker can file a lawsuit and their likelihood of success.

How appeals influence benefits litigation

Disability benefits provided by employers are subject to several important federal regulations. Specifically, the Employee Retirement Income Security Act of 1974 (ERISA) governs disability benefits provided by employers. The policy the company acquires has to conform to numerous statutory regulations. The insurance company should act in the best interests of policyholders when making decisions about claims.

Policyholders also have the right to at least one internal appeal if the insurance company does not approve their claim. What happens during the appeals process directly influences whether the worker is eligible to pursue benefits litigation and their likelihood of prevailing if they go to court. Typically, any evidence a worker might present during a lawsuit must be part of the appeals process with the insurance company.

In other words, all medical documentation and other evidence that could prove the insurance company violated regulations or policy requirements needs to be part of the appeal. If the insurance company continues to deny the worker benefits, then the information available to the insurance company during the appeal becomes the evidence used during the ERISA insurance litigation that follows.

Most people already dealing with the debilitating medical issue find it prohibitively difficult to learn all about ERISA and the appeals process. Bringing in outside support can be beneficial during an ERISA disability appeal or lawsuit. Workers who understand the basics of how ERISA benefits claims work may see the value in obtaining support throughout that process.