ERISA Long-Term Disability Appeals Lawyer
Hi, we’re Erin & Kyle
Our mission is to hold insurance companies accountable for the promises they make.
At our firm, we focus exclusively on helping people with long-term disability benefit issues and long-term care insurance denials. We’d love to help you get the benefits you deserve.
If your employer-sponsored Long-Term Disability (LTD) claim was denied, you’re likely navigating a complex process governed by a specific federal law—the Employee Retirement Income Security Act of 1974 (ERISA). Dealing with an ERISA denial adds layers of procedural rules and challenges when you’re already managing significant health issues and financial stress.
At Sandstone Law Group, our group long-term disability appeals lawyers understand ERISA cases.
You don’t have to face the complexities of an ERISA appeal alone; we provide experienced legal guidance tailored to this unique law.
Understanding ERISA and Your LTD Claim
Most long-term disability insurance policies obtained through a private employer, trade association, or union fall under ERISA. This federal law intended to protect employees’ retirement and welfare benefits, but it also sets strict rules for LTD claims and appeals. These rules often differ significantly from state insurance laws that govern individual policies.
LTD benefits secured through your employer are meant to provide crucial income replacement if a medical condition prevents you from working. However, insurers administering these ERISA plans frequently deny valid claims, making the appeals process critical.
Common Reasons ERISA LTD Claims Are Denied
Insurance companies administering ERISA plans may deny claims for various reasons, often related to the specific requirements and interpretations under federal law:
- Insufficient Medical Evidence (Per Plan Standards): The insurer claims your medical records don’t adequately prove disability according to the definition in the ERISA plan document.
- Plan Definition Disputes: Disagreements over whether your condition meets the specific definition of “disability” outlined in your employer’s plan documents.
- Missed Deadlines or Procedural Errors: ERISA imposes timelines for filing claims and appeals (often 180 days for appeals). Failing to follow procedures correctly can lead to denial.
- Pre-Existing Condition Exclusions: Insurers may invoke clauses within the ERISA plan that limit or exclude coverage for conditions present before enrollment.
- Termination of Approved Benefits: Insurers conduct periodic reviews and may terminate existing benefits based on their own medical assessments, vocational reviews, or surveillance, arguing you no longer meet the ERISA plan’s disability criteria.
Receiving a denial under ERISA can feel like hitting a brick wall, but it’s often the start of a necessary legal process.
The Critical Importance of the ERISA Appeal
Under ERISA, the internal appeal filed directly with the insurance company is not just optional—it’s usually mandatory before you can file a lawsuit. More importantly, this appeal is typically your primary and often only opportunity to submit evidence supporting your claim.
All the medical records, doctor’s opinions, vocational reports, personal statements, and other supporting documents you provide become part of the administrative record.
If you later need to sue the insurer in federal court, the judge will generally review only the information contained in that administrative record created during the appeal. A weak or incomplete appeal can permanently damage your ability to win your case in court.
Giving up after a denial is exactly what the insurance company hopes you will do.
We don’t give up.
Strict ERISA Appeal Deadlines: Why You Must Act Quickly
ERISA regulations typically give claimants 180 days from receiving notice of the denial to file a comprehensive appeal. This can be interpreted by some insurers as a strict deadline. Missing it could mean losing your right to challenge the denial and recover benefits, no matter how strong your medical evidence is.
The financial pressures of being unable to work make prompt action even more critical.
Contacting an experienced ERISA attorney immediately after a denial ensures you have time to gather necessary evidence and build the strongest possible appeal before the deadline expires. Sandstone Law Group offers free consultations to help you understand your rights and timelines without delay.
Navigating Insurer Tactics in ERISA Appeals
- Insurers handling ERISA claims may use various tactics to uphold denials:
- Relying on “paper reviews” by doctors who haven’t examined you.
- Using biased Independent Medical Examinations (IMEs) or Functional Capacity Evaluations (FCEs).
- Conducting surveillance to find activities inconsistent with disability claims.
- Interpreting vague plan language in their favor.
- Issuing burdensome requests for repetitive or irrelevant information.
- Delaying decisions within the allowed ERISA timeframes.
An attorney experienced in ERISA knows how to anticipate and counter these tactics effectively.
How Sandstone Law Group Handles ERISA Appeals
Our approach is specifically tailored to the unique demands of ERISA appeals:
- Free Consultation & ERISA Case Evaluation: We review your denial letter and relevant plan documents to assess your case under ERISA guidelines.
- Building the Administrative Record: This is paramount. We work proactively to gather all necessary medical evidence, supportive physician statements, vocational evidence, and personal declarations before the appeal deadline to create a comprehensive record for the insurer (and potentially a court) to review.
- Analyzing the Plan & Denial: We meticulously review your specific ERISA plan documents and the insurer’s stated reasons for denial, identifying procedural errors or flawed interpretations.
- Engaging Experts: We collaborate with qualified medical and vocational experts to provide objective evidence countering the insurer’s conclusions.
- Drafting Appeals: We submit detailed, evidence-based appeals that address denial and argue why you meet the plan’s definition of disability under ERISA law.
- ERISA Litigation (If Necessary): If the appeal is denied, we are prepared to file suit in federal court. We navigate the specific procedures of ERISA litigation, which typically involves:
- Limited or no discovery (information exchange).
- Review primarily based on the administrative record created during the appeal.
- Decision by a judge (no jury trial).
- Limited remedies (usually focused on recovering owed benefits and potentially attorney fees).
FAQs About ERISA Long-Term Disability Appeals
1. Why was my employer-sponsored LTD claim denied under ERISA?
Common reasons include the insurer finding insufficient medical proof based on plan standards, disputes over the plan’s definition of “disability,” procedural errors, or simply an incorrect assessment by the insurer. Sandstone Law Group analyzes the specific reasons cited in your ERISA denial.
2. Can I appeal an ERISA denial?
Yes, and you generally must appeal directly to the insurer before you can sue. This internal appeal is governed by ERISA regulations and is crucial for building your case record.
3. How long does an ERISA appeal take?
ERISA regulations give the insurance company specific timeframes (often 45 days, potentially extendable another 45 days not including tolling) to decide on your appeal once they receive it. The process of preparing a strong appeal before submission can take several weeks or months, depending on evidence gathering.
4. What evidence is crucial for my ERISA appeal?
The goal is to make the administrative record as strong as possible. This includes complete medical records, detailed supporting statements from treating physicians addressing plan definitions, objective test results, vocational assessments if applicable, and personal affidavits.
5. What is the “administrative record” in an ERISA case?
It’s the collection of all documents submitted by you and considered (whether or not relied upon) by the insurer during the claim and the internal appeal process. In most ERISA lawsuits, the judge’s review is limited to the administrative record. That’s why the appeal stage is so critical for getting all favorable evidence included.
6. Will my ERISA appeal go to federal court?
Many ERISA appeals are resolved favorably during the internal appeal process. However, if the insurer upholds the denial after the appeal, filing a lawsuit in federal court may be the next step. Sandstone Law Group prepares every appeal thoroughly in case litigation becomes necessary.
7. How much does an ERISA appeals lawyer cost?
Sandstone Law Group offers a free initial consultation. We typically handle ERISA appeals on a contingency fee basis—meaning you pay no attorney fees unless we recover benefits for you. We may handle case costs (like acquiring records or expert fees) separately, which we clearly discuss upfront.
8. My ERISA appeal deadline is soon. What should I do?
Contact an experienced ERISA attorney immediately. Given the 180-day deadline and the importance of building a complete administrative record, time is of the essence. Reach out for a free consultation right away.
9. How do I start my ERISA appeal with Sandstone Law Group?
Simply contact us for your free consultation. After screening, we’ll discuss your denial letter, request your plan documents if you have them, and explain how we can help you navigate the ERISA appeal process effectively.
Take the First Step Today: Talk to an ERISA Long Term Disability Appeals Lawyer
Focus on your health; let us focus on securing your benefits. Contact Sandstone Law Group today at (602) 615-0050 for your free, confidential ERISA consultation.