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Many employers provide an employee benefits package as part of an employee’s compensation. According to a March 2022 report by the U.S. Department of Labor, benefits account for close to one-third (29.5%) of employers’ compensation costs for private-industry workers.

You may think of these benefits only when it’s time for open enrollment. At other moments, they might seem like just a list of paystub deductions from your net earnings, such as for long-term disability insurance, short-term disability insurance, life insurance, health insurance, accidental death and dismemberment insurance, and retirement plans (401k and pension). When you need them, however, they are irreplaceable.

In the event of an injury, illness or accident, these employee benefits are there to alleviate the financial impact of being unable to work or having to cover the cost of a medical procedure or treatment.

Unfortunately, it can be common for the benefits that have been paid for – and for which you qualify – to result in a denied insurance claim, seemingly without any good reason.

Employee Benefits and ERISA

In most cases, your right to the benefits provided by your employer is covered under the Employee Retirement Income Security Act of 1974 (ERISA). This law created protections for employee benefits; however, over time it has become less consumer friendly and more difficult to navigate without expert help.

Depending on the situation, receiving employee benefits may involve three steps: filing a claim, appealing a claim denial and filing a lawsuit. Most clients contact us after their insurance claim is denied, because what happens next – the appeals process – can be the most important step in getting benefits approved.

Making an insurance claim and appealing one that is denied can be both confusing and frustrating. What happens during this process can have long-term effects on your rights to your benefits. This is because employee benefits claims differ from any type of contract or insurance claim.

A primary hurdle is that the ERISA law and the accompanying federal regulations create strict timelines. Failure to meet them could mean you could lose out on your benefits, including the right to bring suit against the insurance company that administers them and, if applicable, your employer.

The law also gives insurance companies and employers great latitude to deny claims without much evidence to support their decision. Knowing what the insurance companies need to support a claim for benefits requires experience and expertise. While it seems like the process should be clear and transparent, it isn’t. The language used is particular, and how simple ideas are relayed to the insurance companies matters.

The documents and medical records produced during the ERISA internal-appeal process are important for persuading the insurance company or plan administrator that you, the plan beneficiary, are in fact disabled and entitled to benefits. These records and documents are also the basis of what the court will review once a lawsuit has been filed.

Lawsuits for wrongfully denied insurance claims governed by ERISA must be filed in federal court. The claims are decided without a jury – usually without a hearing – and typically decided only according to the documents submitted during the appeal. What is done and submitted (or not) during the process will influence the outcome of any lawsuit.

In most contexts, the court will be limited to only determining if the insurance company’s decision was reasonable from the documents submitted during the review process. This limitation makes ensuring the accuracy of the appeal – and having a highly experienced lawyer to assist with it – even more vital. Without knowing what an insurance company needs, you will run into great difficulty proving to either the carrier or the court that you are disabled under the terms of the plan.

ERISA Attorneys: Contact Us Today

The seasoned trial lawyers at Gallagher Davis, LLP support company employees in the review and filing of ERISA cases that involve long-term disability insurance, short-term disability insurance, life insurance, health insurance, accidental death and dismemberment insurance, pensions and long-term care.

Our attorneys have experience in all state and federal trial and appellate courts in the St. Louis metropolitan area. We also serve clients throughout Missouri and the Midwest. If you would like to review, file or appeal a claim, we provide you with vigorous advocacy and representation in justly receiving available employee benefits for which you are qualified as you recover. To discuss your case, contact us today at (314) 725-1780.