Updated on May 23, 2019.
You just received the letter in the mail. The insurance company is denying your claim for long-term disability benefits. You are frustrated and upset. The injury was not your fault, and you have done everything that the insurance company has asked you to do. You have been going to therapy and following all the instructions your doctors and the specialists have given you for dealing with the pain, yet you are still unable to perform your job duties.
The letter from the insurance company tells you that you can file an appeal of the denial of your claim. But you do not really know what filing an appeal will entail. Although the human resources department at your work is willing to help, they have a lot of other employees and tasks to occupy their time.
If My Insurance Is Through My Employer, How Does It Work?
If your insurance plan is provided by your employer, it is handled through the Employee Retirement Income Security Act (ERISA). After you’ve suffered an injury that renders you unable to work, you must report it to your employer within four working days following the injury. If you don’t, then you could receive less compensation and further penalties. Once the claim has been filed, the insurer will review all submitted materials from you and your employer. At this point, you will receive either an Admission of Liability, or a Notice of Contest (Denial).
If your claim is being denied, the insurance company might give several reasons. Oftentimes, the insurance adjuster will have insufficient information to approve a claim. If they believe that the injury was not related to your employment, or if the information you provided requires further investigation, your claim could be denied as well.
Do I File a Lawsuit or an Appeal?
Once you’ve received a Notice of Contest, not all hope is lost. Your claim may have been denied, but you do have some legal options. If you have an individual plan, a government plan, or a church plan, you generally do not need to file an appeal with the insurance company but can immediately file a lawsuit in a state court. A lawsuit in state court has numerous advantages because you may call witnesses and present evidence before a jury. If, however, you have a plan under ERISA, then there are strict regulations about how the appeal and claim process must be commenced.
Under ERISA, you must first file an appeal with the insurance company before you are permitted to bring a lawsuit. Generally, you only have 180 days after your insurance claim has been denied to file this appeal. In some instances, you must appeal one time before you are able to bring a suit in federal court. In other cases, you have to go through two levels of appeals before your case is ripe for filing a lawsuit.
If your appeal is denied by the insurance company, then you will be permitted to bring a federal action regarding the denial of your claim. The federal appeals process is different than the state court system. Under ERISA regulations, you will not be permitted to have a jury hear your case. Rather, a judge will make the decision based upon the evidence that you provided to the insurance company in the appeals process. You will not be permitted to present any new evidence or witnesses in the federal lawsuit – only the information that you presented to the insurance company in your appeal will go before the judge.
This makes it extremely important for you to present any and all evidence, such as medical records, witness statements, and doctors’ recommendations, in the appeal to the insurance company. If any significant evidence is left out, it cannot be used in a lawsuit.
Because of the complexity of ERISA claims, it’s important that you hire a professional to guide you through the process. An attorney with experience in long-term disability cases will make sure that all the evidence is provided at the appellate stage and that you meet all the timelines for filing your claims. Additionally, federal lawsuits tend to be rather technical in nature, so give a good amount of consideration to hiring a Colorado ERISA claims lawyer.
A Disability Attorney Who Can Help You
At the Tenge Law Firm, LLC, we understand that you may be going through the most difficult part of your life. Thankfully, you don’t need to go through it alone. Our experienced team can review your unique situation and provide the legal support you need to receive the compensation you deserve. Contact our office now at (303) 665-2929 for a free consultation and learn more about how you can protect your future.