Employees who benefit from employer-sponsored retirement and health plans, such as disability benefits, 401(k) plans, employee stock ownership plans (ESOPs) and profit-sharing plans are protected with the use of the Employee Retirement Income Security Act (ERISA).
An ERISA disability claim may be rejected, however, by an insurance company — causing severe financial strain for the affected applicant. Here’s what you need to know about your options for an appeal:
Understand why the claim was denied
The first step to appealing an ERISA claim denial is to understand why an insurance company rejected the claim. Some common reasons for rejections include the following:
- Insufficient medical evidence: An insurance company may not believe a medical condition is sufficiently disabling to provide coverage and requires additional medical evidence to support a claim. Additional tests and reports may need to be done by an approved medical practitioner.
- Ignoring treatment plans: An insurance company may believe that an employee has not followed the treatment plan set by a doctor.
- Pre-existing conditions: A claim could be denied because a pre-existing medical condition is not covered under an insurance plan.
- Social media posts: Insurance companies may monitor an employee’s social media and use social media posts to deny a claim.
An ERISA claim denial is not always final. Corrections can be made with an appeal to help ensure the disabled applicant receives the benefits they need.
Filing an ERISA disability claim appeal
There are several steps to take for a successful appeal once it is clear why a claim was denied. An employee may need to gather additional evidence to address the denial. A denial appeal letter should be written to have a case reviewed. The denial letter may inform an employee how long they have to file an appeal – typically 180 days. Missing out on this deadline could prevent an employee from receiving benefits.
Legal guidance can help employees craft an ERISA claim appeal letter so they can successfully receive their disability benefits.