ERISA is an acronym for Employee Retirement Income Security Act. Passed by Congress in 1974, it is a federal statute that governs the administration of employee benefit plans and the rights of the beneficiaries under the plan. If your policy (disability, life, etc.) is through your employer, then chances are it is governed by ERISA. Under ERISA, a participant or beneficiary may recover denied employee benefits through a civil action, but only after first exhausting the procedures, as found in the employee plan, by filing appeals with the insurance company.

Insurance companies deny claims for disability benefits for a variety of reasons. However, they most often deny claims on the basis that the insured has not met the definition of “disability” as that term is defined in the policy. A large percentage of claims are denied at the time where there is a change in the definition of disability from your occupation to any occupation. This typically occurs after the insurance company conducts a “review” of the medical information you have provided. The insurance company may have also requested you attend an independent medical evaluation (IME) or have your records reviewed by one of their doctors. Other reasons for denying claims include pre-existing conditions, coverage issues, and/or exclusions or limitations contained in the policy.

Denying claims under the 12 or 24 months mental and/or nervous limitation provision for impairments which are not listed on the DSM-IV is a regularly utilized practice by insurance companies seeking to avoid paying a valid claim for benefits.

Once your claim has been denied, you must “exhaust your administrative remedies” with the insurance company before you are able to file a lawsuit. In other words, you must file a written appeal to the insurance company requesting your claim be reviewed. There are, however, exceptions to this requirement. For instance, exhaustion is not necessary where it would be futile for you to file an appeal. Practically speaking, it is advisable to file an appeal so as to avoid the possibility of not being able to file a lawsuit against the insurance company. It also gives you an opportunity to provide updated medical information for the insurance company to consider.

Insurance companies often try to collect first hand information from a claimant in order to find inconsistencies in information you previously provided to them. They will then use any inconsistencies against you by denying your claim for benefits. Our firm has experience with assisting clients that face this very issue.