Knowing What An ERISA Benefit Denial Concerns

A denial of your claim does not need to be the end of the story. With assistance from an attorney skilled in ERISA law, a benefit denial can be successfully challenged.

At the Law Office of Robert F. Keehn, in Los Angeles, we can help you assert your right to receive the benefits you worked so hard for. Our founding attorney, Robert F. Keehn, has more than a quarter-century of experience providing compassionate representation in insurance and employment matters. This includes the successful resolution of numerous cases under the Employee Retirement Income Security Act (ERISA) when claims were originally denied.

Common Reasons For ERISA Benefit Denials

• Lack of medical evidence: One of the most common reasons for denial is not having enough proof of disability or medical need. Insurers may claim that the medical records, test results or doctors’ statements do not support the claim.
• Missed deadlines: ERISA plans have strict filing and appeal deadlines. If a claimant misses even one, the insurer may deny the claim automatically.
• Policy exclusions and coverage limits: Some benefit plans exclude certain conditions or limit how long benefits are available. For example, mental health conditions or chronic pain disorders may have shorter coverage periods.
• Preexisting conditions: Insurers often argue that a medical issue existed before the policy took effect, which can disqualify the claim.
• Conflicting medical opinions: If an insurance company’s reviewer disagrees with the treating physician, that disagreement alone can be enough for a denial.
• Incomplete or inaccurate paperwork: Even small administrative errors, like missing signatures or forms, can delay or derail a claim.

Steps To Take After A Denial

1. Review the denial letter carefully: The denial letter should explain why the claim was denied and how to file an appeal. Reading it closely helps clarify what evidence or documents the insurer says are missing.
2. Request the claim file and plan documents: Every claimant has the right to see the records used to make the decision. This includes medical reports, notes from the plan’s reviewers and the policy itself.
3. Gather additional evidence: Updated medical records, statements from doctors and test results can strengthen an appeal. Keeping a journal of symptoms or work limitations can also help.
4. Correct any paperwork issues: If the denial was due to a missing form, late filing or other technical error, fix it quickly.
5. Submit a written appeal: The appeal should explain why the decision was wrong, provide new medical evidence and cite the plan language that supports the claim.
6. Consider legal guidance: ERISA law can be complex. Working with an experienced ERISA attorney or insurance lawyer can help ensure the appeal meets all procedural requirements and deadlines.
7. Explore further options: If the appeal is denied, the next step may be filing a lawsuit in federal court. Strict time limits apply, so acting promptly is essential.

What We Can Do About Your Claim Denial

Under ERISA, benefit denials are not the last word. Of course, challenging a claim denial requires a good deal of documentation. In order to get your appeal ready, we will need access to the file used by the insurance company, as well as other information. Fortunately, ERISA requires insurance companies to make these files available to employees whose claims were turned down.

As an experienced ERISA lawyer, Robert can help you appeal the claim denial. When necessary, we can also take your case to a federal judge. We have a proven record of success in these cases and serve clients throughout California.

Confidential, No-Cost Consultation Available

We invite you to talk with us about your legal rights in a no-obligation initial consultation. Call 424-777-3964 or complete our brief email form.