What are Common Reasons for an ERISA Claim Denial?

The Employee Retirement Income Security Act (ERISA) was enacted in 1974 to protect employees’ benefits in private industry. This law sets minimum standards for most voluntarily established pension and health plans, ensuring that employees are protected against fraud and mismanagement. ERISA is crucial because it requires plans to supply participants with information about plan features and funding, establishes fiduciary responsibilities for those who manage and control plan assets, and grants participants the right to sue for benefits and breaches of fiduciary duty.

Despite these protections, ERISA claims can still be denied for a variety of reasons. Understanding these common reasons can help individuals better prepare their claims and increase their chances of approval. At Bartolic Law, we have handled numerous ERISA claim denials and are ready to help you appeal.

1. Insufficient Medical Evidence:

One of the most frequent reasons for an ERISA claim denial is the failure to provide adequate medical evidence to support the claim. Insurance companies often require comprehensive documentation that clearly demonstrates your medical condition and its effect on your ability to work. For instance, a claimant with a disability due to chronic pain must submit detailed medical records, physician statements, and test results. In the case of Tassone v. United of Omaha Life Ins. Co., the court awarded long-term disability benefits after finding that the insurer’s doctor failed to provide objective evidence of functional impairment, highlighting the importance of thorough medical documentation.

2. Missed Deadlines:

ERISA plans have strict deadlines for filing claims and appeals. Missing these deadlines can cause an automatic denial. It’s essential to review your plan documents carefully to understand the timelines and ensure that all submissions are timely. Many individuals are unaware of these deadlines until it’s too late, emphasizing the need for vigilance and prompt action.

3. Lack of Coverage under the Plan:

Sometimes, claims are denied because the condition or treatment is not covered under the plan. This can occur if the plan has specific exclusions or if the claimant misunderstands the benefits. For example, certain plans may exclude coverage for mental health conditions or specific types of surgeries. In such cases, it’s crucial to thoroughly read and understand your plan’s summary plan description (SPD) to know what is and isn’t covered.

4. Administrative Errors:

Occasionally, claims are denied due to administrative errors, like incorrect data entry or misinterpretation of the policy terms. Ensuring all information is accurate and double-checking submitted documents can help avoid these pitfalls.

Strengthening Your ERISA Claim:

To enhance the likelihood of a successful ERISA claim, individuals should:

• Gather Comprehensive Documentation: Ensure all medical records, physician statements, and other relevant documentation are complete and up-to-date.
• Understand Your Plan: Familiarize yourself with your plan’s terms and conditions to ensure your claim aligns with the coverage provided.
• Meet All Deadlines: Keep track of all filing deadlines and submit your claims and appeals promptly.
• Seek Professional Assistance: If faced with a denial, consulting with an ERISA attorney can provide valuable guidance. Legal professionals, like those at Bartolic Law, can help navigate the complexities of ERISA, ensuring that your rights are protected and increasing the chances of a positive outcome.

Contact Us For Help

While ERISA provides significant protections for employees, navigating its requirements can be challenging. Understanding some of the common reasons for claim denial and taking proactive steps can greatly improve the chances of success. If you encounter difficulties, don’t hesitate to seek the help of an experienced ERISA attorney to advocate on your behalf. Bartolic Law is dedicated to helping individuals fight for their rights under ERISA and obtain the benefits they deserve. Contact us today for a consultation.