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How to File an ERISA Claim

Most of us don’t think that we will become disabled. Yet 13% of the American population has a disability – and injury or illness could strike any of us at any time. Having long-term disability insurance is one way that you can protect your financial stability if you are unable to work due to a disability.

Long-term disability (LTD) plans that are sponsored by an employer are governed by a federal law that is known as ERISA. To apply for benefits, you will need to file a claim with the insurance company. With this application, you will need to demonstrate that you have a disability that is covered under the policy and that this disability leaves you unable to work.

Bross & Frankel assists individuals with all phases of ERISA claims, from filing a claim to appealing a claim denial at the administrative level to filing a federal lawsuit. If you are contemplating an LTD claim, our ERISA disability lawyers can help. Reach out to our law offices to schedule a free consultation today.

What Is an ERISA Claim?

In 1974, Congress passed a law that was designed to protect workers who participate in their employers’ employee benefit plans. The Employee Retirement Income Security Act, or ERISA, sets minimum standards for most voluntarily established health and retirement plans in private industry. It also governs disability insurance plans that are sponsored by an employer or union.

If you participate in a disability plan offered by your employer, it may be covered by ERISA. This is important because ERISA provides several key protections for employees:

  • It makes the long-term disability insurance company a fiduciary, which means that it must act prudently in your interests when administering an ERISA claim.
  • The insurance company must provide you with a full and fair review when deciding a claim. This includes adopting reasonable claims procedures for administering claims; allowing you to appeal a claim denial with someone who wasn’t involved with the claim denial; deciding your claim and appeal within a set period of time; reviewing all of the evidence that you submit as part of your disability claim; and consulting with healthcare professionals (such as doctors) when deciding that involves a medical judgment.
  • States may regulate long-term disability insurance.
  • The plan administrator must disclose relevant information, including the plan description and the specific reasons for a claim denial. 
  • If an insurance company wrongfully denies your claim or terminates your benefits, you have the right to file a lawsuit in federal court.

If you have any questions about whether your LTD policy is governed by ERISA, an experienced long-term disability lawyer can help. During a free claim review, they will listen to your story and give you advice on your rights and options for filing an ERISA claim or appealing a decision made by the insurance company.

How to File an ERISA Claim

There are several steps involved in filing an ERISA claim. The first step is to review your disability insurance policy. The policy is a type of contract, and will spell out your rights. When reading your policy, you should check for key terms such as what is considered a disability, what type of evidence you will need to support your claim, and how long you must be disabled before you can file a claim (known as the elimination period).

Once you have a good understanding of the terms of your policy, the next step is to gather all necessary evidence. To be approved for LTD benefits, you will need to prove that (1) you have a disability that is covered by your plan and (2) this disability prevents you from working (either in your own occupation or any occupation, depending on the terms of the policy). Examples of evidence that you might include to support your claim include medical records, results from any medical tests, medication lists, and a letter from your treating physician explaining your limitations based on your disability.

After you have put together all the necessary evidence, you will file your ERISA claim with the plan administrator. Carefully check the plan document to make sure that you are following the correct procedures, such as including an employee statement and a statement from your employer.

Once the application has been filed, you will wait for a decision. Under ERISA, the plan administrator has 45 days to decide on the claim. However, if they have a valid reason that they cannot decide within this period of time, they can request 2 extensions of up to 30 days each.

If your claim is denied, then you have the right to appeal under ERISA. You must file an administrative appeal within 180 days of receiving the denial notice. During the appeals process, you can submit additional evidence and make arguments as to why the denial was incorrect. It is important to build a solid administrative record during this stage because if you file a lawsuit, it will generally be limited to this evidence.

The last step in the process is to file a federal lawsuit for wrongful denial or termination of benefits. Filing a lawsuit is only necessary if your claim and any administrative appeals are denied. It is the last opportunity to have this decision reversed and to be awarded benefits.

Filing an ERISA claim can be overwhelming, especially if you are already dealing with an injury or illness. A New Jersey ERISA disability attorney can help you with every step of the process. Our law firm will review your policy for you, help you build a strong administrative record, assist with the paperwork, and handle any appeals on your behalf.

What Happens If Your ERISA Claim Is Denied

If you receive a denial notice from the long-term disability insurance company, then you must decide what you want to do next. If you believe that the decision is wrong, then you can file an appeal. For any ERISA claim, you must file an administrative appeal with the insurance company.

Typically, you have 180 days to file an administrative appeal. With this appeal, it is critical to submit evidence to build the administrative record. As noted above, if you file a federal lawsuit, you will not be able to submit additional evidence of your disability or how it affects your ability to work. Evidence may include:

  • Vocational expert reports
  • Objective medical testing
  • Medical opinion reports
  • Residual functional capacity reports
  • Job description evidence from the Dictionary of Occupational Titles
  • Affidavits (sworn letters) from key witnesses such as your boss, coworkers, and family members about your disability and how it affects you.

If you don’t submit sufficient evidence during the appeals process, it could affect you in two ways. First, your appeal will likely be denied if the plan administrator does not find that you are unable to work due to your disability. Second, it will limit your ability to win a legal action down the road.

For many people, the thought of appealing a long-term disability claim denial is daunting. It can be challenging to gather the right kinds of evidence, fill out the appropriate paperwork, and make strong arguments in favor of your claim. Our seasoned ERISA disability attorneys can help you through each step of the process, from filing an initial claim to appealing any wrongful denial or termination of benefits. We will fight for your right to benefits and stand by your side through each step. 

Filing for Long-Term Disability? Give Our Law Firm a Call.

In an ideal world, being approved for long-term disability benefits would be a matter of simply filling out an application. Unfortunately, insurance companies often make it difficult to get benefits. An experienced New Jersey ERISA disability attorney can help you with the process, from filing the initial application to handling any appeals of a denial or termination of benefits.

At Bross & Frankel, we are dedicated to helping people with disabilities get the benefits that they are entitled to under the law. We represent clients who are seeking all types of disability benefits, including Social Security disability, veterans’ benefits, long-term disability, and workers’ compensation. To schedule a free claim review with a member of our legal team, reach out to our law offices at 866-311-3796 or fill out our online contact form.

My ERISA Claim Was Denied. What Can I Do Next?

After your ERISA claim is denied, the first step is to file an administrative appeal. You may need to file two administrative appeals before moving forward with any further steps. If your appeals are denied, then you may file a lawsuit in U.S. District Court. If your lawsuit is successful, then you may receive disability benefits, past benefits due, and attorney’s fees.

Bross & Frankel helps people with disabilities get the benefits that they are entitled to under the law. Reach out to our law offices today to schedule a free claim review with a New Jersey long-term disability benefits attorney.

Do I Need a Lawyer for My ERISA Claim?

You are not required to hire an attorney to file an ERISA claim or to file an administrative appeal. However, you will typically need a lawyer to file a lawsuit in federal court. It is also a good idea to have legal representation earlier in the process. Having an attorney can increase the likelihood of your claim being approved, as they will analyze the insurance policy and work to gather the evidence necessary to support your claim.

This part is particularly important as if your case goes to court, then you will be limited to the information that exists in the administrative record. The ERISA disability lawyers at Bross & Frankel will work hard to build a strong administrative record with an immediate goal of getting your claim approved – and to protect your interests if you need to file a lawsuit. Give us a call to schedule a free initial consultation with a member of our legal team.

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Client Reviews

I thought I could apply for social security on my own and breeze through the process. After being denied my neighbor told me about Bross & Frenkel, so I gave them a call. Mr. Bross called me directly and took on my case.

- Pun!Kin

Rich Frankel is a great person and made me feel taken care of through all my disability issues with the VA and my employer. He is very knowledgeable of the VA disability and employment law and I thank him for all of his help.

- Bernice Williams

Very helpful for our family and helped in a timely manner.

- Bernadette Barricella Forbes

After the first interview, the process seemed to move right along. All the paperwork was filed fast and emails were sent on detailed updates. SSI is a very slow and agonizing journey, but it’s good to have representation that knows what to …

- Ernest I

Bross & Frankel, wow you guys are amazing! This has been a long tedious process and I thank you all so much for successfully representing me, I would definitely recommend you’re office to anyone!! Thank you again!

- Sandra R
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