ERISA law or California Insurance Claim law:
Which Applies?

ERISA claims are processed very differently from California insurance claims. ERISA law is federal and applies to most employee benefit plans. Non-ERISA California insurance claims are covered by state "bad faith law." San Diego lawyers Stennett Casino have handled both types of claims for years. We have obtained benefits for many clients whose long-term disability or life insurance claims were initially denied. We can help you with your ERISA claim and appeal or your California insurance claim.

California law applies to every insurance policy issued to a California resident, except for policies in employee benefit plans subject to Federal ERISA law.

Where California law applies, insurance companies must use "good faith and fair dealing" to not deprive their insureds of the policy benefits or protections. An insurance company acts in "bad faith" where it fails to fully investigate a claim or objectively evaluate a claim. The insurance company must diligently search for evidence supporting the claim. Looking only for evidence to deny the claim is bad faith.

There are three levels of wrongful conduct by an insurance company. As the conduct worsens, the company's potential liability increases.

As a practical matter, insurance companies rarely pay anything beyond the first level (policy benefits) unless an attorney for the insured person uncovers evidence and provides legal arguments that a company acted in "bad faith."

The Employee Retirement Income Security Act of 1974 (ERISA) covers most employee benefit plans, including disability, life, and medical insurance and pension benefits provided by an employer.

ERISA has a two-step claims procedure. You first must file a claim, with proof that you deserve benefits, with the Plan's administrator. If the Plan denies your claim, you have the right to appeal, and the Plan's administrator will review your claim again. There are usually deadlines both for submitting your claim and filing your appeal, although it may be possible to file for a deadline extension. You are responsible for proving your claim at each stage.

Unfortunately, most Plan insurers work to find reasons to deny your claim rather than to help you prove it. Whether our clients retain us before filing their claim or before their appeal, our specialized knowledge of ERISA and insurance company practices enables us to fully document the grounds for benefits. We gather all the documents, seek out additional experts or specialists where needed for full documentation, and often interview witnesses to the events affecting our clients and their claims. Where policy requirements or the law is in dispute, we compile legal support for the claim. We prepare appeal documents with indexes to the supporting evidence. We know that it is crucial to place as much documentation supporting your claim as possible in your claim file, because any later review in federal court is usually limited to the contents of the claim file.

Once you have exhausted your administrative appeal rights you have a right to bring legal action for benefits under ERISA Section 502(a). If a claim has been fully documented and was denied for improper reasons, we will file suit in court to obtain benefits. Clients who win ERISA lawsuits obtain past benefits and the right to ongoing future benefits, and attorneys fees.

We are experienced claim attorneys and can help you by: