Experience. Results.

How to appeal an ERISA claim denial

On Behalf of | Nov 9, 2021 | ERISA

The Employee Retirement Income Security Act of 1974 was established to address potential problems workers may have when needing benefits associated with their employment. New Jersey employers are required to provide specific information and updates for all employees regarding their benefits packages. Many benefits packages include long-term disability benefits as well as short-term disability benefits, but many times claims for these employment incentives are often denied when the employer or insurer is contesting eligibility or extent of inability to work. Luckily, ERISA has protocols to follow when a claim is denied.

Steps employees can take

Insurance companies providing health care coverage for employees of clients are well-known for being meticulous and secretive when denying claims. In fact, before ERISA was enacted, employees often could not access information regarding any of their claims that were being held by the insurer. As the law applies now, this is no longer the case after a court case established this right of access. However, the result is still often the same denial often based on testimony from a company physician who is submitting a counter-claim medical opinion at the company’s request. At this point, legal representation from an ERISA attorney may be necessary.

Going to court

Court filings following an in-house appeal denial by an ERISA insurer can be detailed legal matters that often will require court ordering of information needed in building a solid case against the insurer. How the insurer arrived at a decision to deny benefits is often controlled intellectual property that they do not want to be revealed. However, New Jersey courts can demand disclosure of any and all information used in an ERISA benefits claim denial.

New Jersey workers should never accept the decision of their insurance provider has the final say in a benefits claim. The court has established full rights to information access being held by the company, but this commonly requires going to court because employees are very limited in appealability within the system.