In 1974, Congress passed a law that regulates your employee benefits. Known as ERISA (the Employment Retirement Income Security Act) this law covers your retirement, disability, health, life and other employment-related benefits. It details the responsibilities of your employer regarding your employee benefit plan, and it outlines the steps you can take if you believe your rights are being violated. ERISA is a Federal law. State laws will not apply since they are preempted by ERISA. However, if you are employed by a governmental entity then ERISA does not govern your employment benefits. (State laws of insurance “bad faith” may then apply).
ERISA has a two-step claims procedure. You first must file a claim, with proof that you qualify for benefits, with the Plan’s Administrator. Typically, your employer will provide you with the claim forms. Most disability, life and health Plans are underwritten by an insurance company. (Unum, Prudential, Met Life, Hartford, etc.). In these cases your claim will be reviewed by the insurance company (referred to as the Claim Administrator). Both the Plan Administrator (employer) and the Claim Administrator (insurer) have a fiduciary responsibility “to act solely in the interest of the [Plan] participants and beneficiaries.” However it may be fatal to your claim to assume that the Administrator will assist you in proving your claim. You are responsible for proving your own claim.
If the Plan denies your claim, you have the right to an administrative appeal. The Claim Administrator will review your claim a second time. You have a right to obtain a copy of the administrator’s file. Get it! This file will tell you what they have reviewed and what their own internal consultants (medical reviewers, vocational analysts, surveillance video) are saying about your claim.
The appeal process is a critical point in your claim. A time when you should at least talk to an attorney with expertise in ERISA. The reason being that if your appeal is also denied your remaining remedy is to file suit in Federal court. ERISA limits your rights in court. You have no right to a jury and virtually no right to perform discovery. Thus all of your discovery needs to be done during the administrative appeal process. When the judge reviews your case he will be limited to reviewing what is in the administrative file. You can not hold back the “good stuff” for trial. If it was not presented during the administrative review then the judge will not consider it. There are many things that can be done to bolster your claim. See the article, “Excuses…”, for ideas.
There are usually deadlines both for submitting your claim and filing your appeal, although it may be possible to obtain a deadline extension. Make sure you comply with these deadlines.
It is highly recommended in these technical ERISA cases that you speak to an ERISA attorney early in your case. If you retain an attorney make sure he/she has specialized knowledge in ERISA and insurance company practices. An attorney can help you to fully document your claim by gathering all the documents, seek out additional experts or specialists, interview witnesses and compile legal and factual support for your claim.