Challenging The Denial Of An Employee Benefit Claim

As the beneficiary of an employer-sponsored benefit plan, you have a number of rights guaranteed to you through the Employee Retirement Income Security Act of 1974, or ERISA. Carla N. McKain has spent much of her career as a lawyer representing clients in ERISA-related matters.

Our firm can help you with all of the following and more:

  • Obtain documents and assess the benefits to which you are legally entitled
  • Guide you through the claims process and the appeals process if your employee benefit claim is denied
  • If warranted, pursue your case diligently in federal court in order to get your benefits reinstated

Crucial Deadlines For ERISA Appeals

To exercise your rights under ERISA, you and the claims administrator (usually an insurance company) must follow the timelines that the act mandates. This timeline begins when you file a claim under your benefits plan. After that, your claims administrator must follow these deadlines:

  • For a disability claim, the plan administrator has 45 days to make an adverse determination (deny your claim), with up to two 30-day extensions available to them if the administrator requests them properly.
  • For a health care claim, there are different mandatory time periods for urgent care, pre-service, post-service and concurrent care claims, with the longest decision-making period being 30 days for post-service claims. The other claims have much shorter deadlines.
  • Retirement and other benefits permit the administrator to take up to 90 days to decide.
  • The claimant (you) typically has 180 days from the date of the denial to appeal the decision.
  • The plan administrator must decide a disability claim appeal within 45 days, with one 45-day extension if properly requested. For health care claims, the decision time frame varies depending on the type of claim. For all other claims, appeals must typically be decided within 60 days of the plan's receipt of the appeal.

Our firm can help you build a strong case for your appeal during this internal review period. For example, in disability cases, we can schedule (and attend) your independent medical examinations, collect statements from relevant medical professionals, and research and document all aspects of your claim.

The Importance Of The Administrative Record

If your appeal is denied again during the internal review and you decide to file a lawsuit, your case will be reviewed by a judge, typically through a motion that provides the paper record put together during the appeal process, called the administrative record. It is critical that you make the strongest appeal possible, not only to overturn the denial but also in preparation for litigation. If you have not prepared a convincing appeal record for challenging your denial, it is unlikely you will prevail in court.

We Will Fight For The Benefits You Deserve

Having a qualified attorney at your side during an ERISA appeal is a must. Our firm is located in Ithaca, but we serve clients from across New York and anywhere else you may be located in the United States. To set up a case consultation appointment, call us at 800-724-3208 or use our convenient online intake form.