What Should You Do If Your ERISA Claim is Denied? Advice on How to Get Help for Disability Claims in Cleveland, Ohio

There are few things quite as frustrating as a denied insurance claim – especially if that claim can mean the difference between recovering in comfort and struggling to maintain your lifestyle. This is often the case for those who file claims covered under the Employee Retirement Income Security Act, also known as ERISA.

ERISA refers to the 1974 federal law that mandates limited coverage for voluntary benefits programs, like health insurance and retirement plans, that are provided by private companies. When people speak of “ERISA plans,” they’re generally discussing disability insurance, which is a type of insurance that helps to pay for the needs of an employee while they recover from an accident. These are voluntary benefits provided by employers, which may either be fully funded by the company or by payroll deductions for those who enroll; this is one of the main differences between ERISA plans and workers’ compensation, which is mandatory and always paid for by the employer. ERISA plans also generally cover accidents regardless of how or where they occur, unlike workers’ compensation, which only covers accidents that occur while performing your job.

As ERISA plans are voluntary and managed by insurance companies, they have strict requirements and can be difficult to claim; it’s not at all uncommon for a claim to get denied even if it fully matches the stipulations of the program. In this case, you have the right to appeal – and you should always do this with the help of a qualified ERISA disability lawyer, who can guide you through the appeals process and ensure you have the strongest claim possible. Let’s take a brief look at the appeals process, which your disability lawyer will help you as you recover from your injury.

First, Double Check the Plan’s Requirements to Learn the Appeals Process and Ensure That You Have All the Paperwork Necessary

If you’re appealing a denial, it’s essential that you fully understand the plan and what you need to do to appeal. Your lawyer will also take a look at the plan and help you decide how to approach your appeal, including the deadlines and the paperwork that must be filed. Be sure to keep copies of all communications related to your claim, and to have all your documents together so that if you need to, you can send them again.

You’ll Start by Requesting an Internal Review

When you first get the denial, get to work with your lawyer requesting an internal review; essentially, you’re asking the insurance company to take a second look and be sure that your claim doesn’t match their requirements. This will take the form of a written statement, which your lawyer can help you write, and any supporting documentation you believe will help prove your case.

You must file your request for an internal review within 180 days of getting your denial; the insurance company will then have 45 days to conduct a review, but they can ask for an extension of another 45 days. Once they’re done, they’ll send you a written statement explaining their judgment. If you were denied, they need to explain why.

If You’re Denied Again, You Can Request an External Review

Should you be denied after the internal review, you can request a review by an independent third party. In short, you’re asking for a second opinion, just like you would if your doctor gave you a diagnosis you felt wasn’t right. Your lawyer will help you file this request for an external review, which you must file within four months of getting the insurance company’s second denial. This means you have a bit less time than you did to file the request for the internal review.

Just as with the internal review, the third party now has 45 days to make a decision, which will be legally binding for both you and the insurance agency; in other words, neither of you can dispute what this third party says.

If You’ve Still Been Denied, You Can File a Lawsuit Against the Insurance Company

The fact that you may have to go to court is one of the reasons that it’s essential that you start working with an ERISA disability lawyer as soon as you file your claim. By working with them, you can be sure that they’ve documented the entire process and proven that you’ve acted according to the law the whole time. They’ll also have all the documentation they need to prove your claim, from medical records to your written statements while requesting the two reviews.

It’s frustrating to be denied something to which you are entitled through your company benefits package, but by working with an ERISA disability lawyer in Cleveland, Ohio, you have a far better chance of having your rightful claim approved. You’ll have an advocate in your corner every step of the way, someone who understands what you’re going through and who has the legal knowledge to help prove your claim. If you’ve filed an ERISA claim, be sure to reach out to a Cleveland, Ohio disability lawyer right away.