Should I go for ERISA appeal?

Submitted by Anonymous (not verified) on Tue, 03/05/2013 - 07:41

I had been receiving my LTD benefits for the past 7 months. Suddenly, it was terminated. How can I reinstate the benefits? Will I need to re-submit the information and appeal or just ask for the file first?

Posted: 05 Mar 2013 01:00 Post Subject:

If this is an ERISA matter, there is a very specific ADMINISTRATIVE APPEALS process that must be followed to the "T". Miss one step along the way, and you completely lose the right to sue in most cases.

First, they have to tell you the reason for your benefits termination. Did they do that? Or did they simply stop paying? Your appeal would need to state a cause of action . . . unfair termination of benefits, failure to state a reason for termination, etc. When they send a claim termination letter, they must inform you of the right to appeal, how much time you have, and to whom you address that request.

You generally have only 30-60 days to file an administrative appeal with the Plan Administrator. The Summary Plan Description ("SPD") document will also tell you who that is, and their address (you were supposed to be given a copy every year). There is either a formal appeal form, or you or your attorney/claim advocate need to write a formal letter SPECIFICALLY stating that you are APPEALING the decision to terminate your disability benefit, and why.

There was a recent appeals court case in which a person's attorney wrote a letter asking for documents "so we may consider our decision to appeal" but without expressly stating, "my client is appealing the termination decision". When the case went to the appellate court after being tossed by the district court, the appeals court agreed that the words "so we may consider our decision to appeal" was NOT proper notice that an appeal was being filed, as the attorney later argued. The letter was also not addressed to the proper person/address for filing an appeal as required by the SPD and stated in the claims denial letter initially sent to the plaintiff.

When the attorney finally wrote a formal appeal letter, guess what? It was several days beyond the time limit to file an appeal, and the plaintiff lost ALL RIGHTS to sue the Plan's Administrator. You do not want to make the same mistake.

File everything on time or, preferably as soon as possible. Delays only increase the chance of making a dreadful mistake.

You must "exhaust" all of your administrative remedies before you may sue in an ERISA matter. In some cases, a denial of the first administrative appeal is sufficient to provide the ability to sue. When the Plan Administrator also has the right to determine a person's disability status (usually happens when the employer makes the insurance company the Plan Administrator -- happens about 75% of the time), there can be a serious conflict of interest, and the courts will hammer the Administrator for abusing its privilege.

If you do not have a copy of the SPD or the Appeals Procedure, you need to contact the Administrator ASAP. You can do that by telephone, but you need to follow it up with a mailed written request sent Certified Mail, Return Receipt Requested, to prove they received it. Do this quickly!!

You MUST follow the procedure exactly as described, mailing your appeal to the proper person and addrress, and with any required documentation. As long as you follow all the "rules", if you continue to be denied a benefit, then you will be able to take the matter to court for final adjudication.

In my professional capacity as a Life & Disability Insurance Analyst, I can provide claims advocacy for persons in your situation.

Posted: 08 Mar 2013 09:31 Post Subject:

Before you appeal, you must try to find out about the basis for termination. Yes, ask for the file first. Provide detailed info in a letter and point out the reasons why you disagree. Try not to start the administrative appeal, before you accumulate sufficient information. You have some time in hand to start the appeal process.

Posted: 08 Mar 2013 03:24 Post Subject:

Try not to start the administrative appeal, before you accumulate sufficient information. You have some time in hand to start the appeal process.

You cannot make this statement because neither you nor I have any idea how much time has elapsed. Filing an appeal one day too late is FOREVER. From my perspective, your advice is wrong.

An appeal letter does not necessarily have to state all of the points on which the appeal is based. There will be further inquiry and an opportunity to present one's case. The appeal letter can request the claim file and any other information necessary.

But filing the appeal itself is the most important thing. Without that, all could be lost.

An appeal letter can simply state, "I have received your letter indicating my benefits have been terminated as of MM/DD/YYYY. I disagree with that determination and am appealing your decision. Please provide me with a copy of your entire claim file so that I may properly prepare for the administrative hearing you must conduct. Once I have had the opportunity to review my file, I will be able to state the basis of my appeal with specificity."

That's all it takes to preserve one's rights. You don't have to be any more specific just to give notice that you are appealing a benefits termination decision. If they deny the appeal simply on the basis of "lack of specificity" without providing the claim file as requested, that's an entirely different matter that can be appealed to the next higher level, and eventually lead to a court battle.

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