The “Good” of ERISA: Obtaining Your Claim Record

There is a lot of unfairness for claimants and participants with ERISA. In the words of the United States Department of Labor, “The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans.”

ERISA may apply to long-term disability, short-term disability, life insurance, pension and retirement benefits.

There are a lot of bad things about ERISA, but there are also good things about ERISA that if used to your advantage can drastically and positively impact your claim.

The first good thing about ERISA is that unlike a state law insurance claim, an ERISA claim has disclosure obligations. That means before you file a lawsuit, the insurance company, the plan administrator, or the claims administrator, whoever is deciding the claim, has an obligation to produce certain documents whenever there is adverse action taken on your complaint. And, clearly a decision to not pay your benefit is that adverse action.

At that point in time, you have a right to request in writing a copy of the claim record and all of the documents which were relied upon to make that decision. These documents should be produced within 30 days of the receipt of your request for those documents.

One thing many people don’t know but that is an important advantage with ERISA is that before you go into litigation, the courts want you to exhaust every effort to convince the insurance company, the plan administrator, or the claims administrator to pay your claim.

It is crucial that you take advantage of this “good thing” about ERISA and request your claim record. Often, the letter denying your claim won’t make sense to you and may contain boilerplate lanugage that states you don’t meet the definition of disability or your medical condition doesn’t rise to such severity as to impose any restrictions or limitations. And, all these decisions will have been made about you without ever looking at you or without talking to your doctors. Unfortunately, many claims are denied simply because they can deny them.

If you don’t request the claim record, you are shooting in the dark, and you won’t know the real reason why your claim was denied. If you need assistance after your long-term disability claim has been denied, contact an experienced ERISA disability lawyer or long-term disability lawyer today at 800-284-9309.

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