Why Your ERISA Insurance Claim May Be Denied

Long-term disability policies offered by employers are administered under ERISA, or the Employee Retirement Income Security Act. ERISA was intended to offer American workers relief by protecting them from any mischievous employers who promise significant pensions but disappear when the workers are almost retiring. In addition, ERISA also regulates the conduct of insurance companies managing employee benefits.

In the event that you become disabled and can no longer work, you may be entitled to benefits under the employer’s long-term disability plan. ERISA offers disabled workers monetary benefits until they recover and get back to work. However, it is also not uncommon for ERISA to deny your claim or coverage. Continue reading to learn more about ERISA claims and the reasons they may be denied.

Lack of Medical Evidence

One important part of recovering benefits is ensuring that your disability meets the necessary criteria. Most ERISA claims may be denied because the claimant doesn’t sufficiently prove their disability with adequate evidence. Some of the common issues that may lead to the denial of your claims include:

• Failure to undergo regular medical treatment or canceling your medical appointments
• Failure to provide complete medical records
• Failure to offer a statement from the treating physician about the severity of your prognosis or condition
• Failure to adhere to your doctor’s recommendations

Pre-Existing Conditions

Most ERISA claims are denied because of the exclusion in your disability policy. Many disability policies may include an exclusion for any pre-existing conditions.

For instance, if you were treated for a condition long before your insurance coverage began, the claims administrator can deny your claims under the exclusion of pre-existing conditions. This may happen even in cases where the medical condition is unrelated to the current disability.

The Applicant Does Not Satisfy the Definition of Disability Captured in the Policy

Reviewing the fine print of the policy is important, as it will help you determine the exact definition of disability and determine whether the applicant qualifies or not. Some disability policies consider applicants disabled if they are unable to fulfill the duties of the specific occupation. Other policies may only consider the applicant disabled if they are unable to perform any job.

It is important to check the ERISA policy description to confirm the conditions that may be limited or excluded. Working with an attorney will help you examine your ERISA Long-Term Disability Insurance policy to determine if your case has any reasons for denial.

Errors in Your Application Process

Many ERISA claims denials result from run-of-the-mill mistakes that happen during the application process. Some of the errors that may lead to a denial include:

• Failure to meet set deadlines
• Failure to provide accurate information
• Failure to include all the necessary details

Working with an attorney who specializes in ERISA claims will help you avoid these reasons for denial. If your disability claim is denied, your lawyer will help you file an appeal that will overturn the denial.

Missed Deadlines

Denial of an ERISA long-term disability insurance claim may occur if deadlines are missed. Although this may sound simple, determining the deadlines for submitting information can be challenging.

In some cases, the information may be submitted promptly but may not be received by the set deadline since it was sent to the wrong address or place. A seasoned long-term disability insurance attorney may ensure all paperwork needed for applications and appeals is filed properly and on time with the required documentation.

When Video Surveillance Shows Evidence That Contradicts a Claim

It is not unusual for people seeking or receiving long-term disability benefits to be put under video surveillance at the insurance company’s request. If investigators record the applicant carrying out duties that contradict disability claims, then your application may be denied or the benefits stopped.

Therefore, when seeking disability benefits, it is important to adhere to the doctor’s advice with regard to restricting activities or utilizing assistance, such as a walker or cane.

Contact an Attorney to Assist with Your Denied Disability Claims

Navigating the ERISA disability appeal process on your own can be overwhelming, especially when dealing with a severe physical injury or mental illness. Even if you navigate the procedural challenges to keep the claim alive, you may not know how to support your entitlement to these benefits.

Furthermore, insurance companies may deny claims to avoid payouts. And just because you get a denial does not mean you are not entitled to all the benefits under your policy.

If your ERISA insurance claim is denied, you have up to 180 days to appeal the denial. Do not hesitate to seek help from a legal professional. Your attorney will ensure additional evidence is available to support your claim. This may be a doctor’s report and testimonies from your family members or co-workers who are familiar with your condition or circumstances. Attorneys are legal experts and will take time to understand the circumstances that led to the denial and assist you in filing a successful appeal.