The ERISA Claims Process: What You Need To Know

Filing a claim under ERISA, the Employee Retirement Income Security Act, can be quite complex. We asked Ron Dean, a California attorney who has been engaged in employee benefits litigation primarily on behalf of participants for over 30 years, to provide an overview of the process.

The process – in a nutshell

The process of filing an ERISA claim has two general components, according to Dean, who told us, “The law says that you (a) must file a claim, and (b), must exhaust the plan’s administrative processes (with minor exceptions) before you can file a lawsuit. If you file a lawsuit too early, it can be dismissed and your claim barred. If you miss the time limits for complying with the plan’s administrative processes your claim may be forever barred. If the Plan misses its time limits for responding to your claim, nothing really bad happens to it.”

However, Dean also pointed out that insurance companies have an upper hand in the process. He said, “In an ERISA claim, you don’t get a jury, you get a short hearing based on a paper record and the thumb of the law is placed heavily on the insurance company’s side of the scales of justice.”

The importance of the administrative record

As Dean said, claimants are only provided with a short hearing based on a paper record, commonly referred to as an administrative record. He explained why this record is so important:

When you go to court in an ERISA benefits case, most times the only evidence the judge will look at is the evidence you timely submitted to the insurance company before you filed your lawsuit. A plan cannot require you to go through more than two appeals, but as you can see, you want to present your strongest possible case to the insurance company. This means reading carefully every ground the insurance company gives for the denial and making sure that you answer each one.

Your response should be thorough, complete, patient, calm and objective. Remember, your appeal isn’t just for the insurance company, it’s also for the judge who just wants to get to the bottom of what the case is about.

The appeals process

Claim decisions can be appealed; however, the process isn’t exactly employee-friendly, as Dean points out:

When the plan denies your claim, it’s required to send you a letter giving the reasons for the denial and telling you what your appeal rights are and how long you have to appeal. You are entitled to have the Plan send you all of the “relevant documents” and you should immediately write to the plan asking for just that – “all the relevant documents.”

You should not tell the plan that you want to appeal until you have those documents and have collected all your evidence and are ready to present your full appeal to the plan. Make sure you present your appeal within the time limits provided by the plan, though. If you appeal too soon, the Plan will use that opportunity to promptly deny that appeal before you’ve had a chance to send them all your evidence. This may prevent you from giving them evidence to the plan or, later, to the judge.

Best practices

We asked Dean to provide some best practices on what an employee can do to make sure the claims process easier. Here’s what he recommends:

  1. Obtain “all the relevant documents” from the plan;
  2. Collect all your evidence;
  3. Respond to every issue raised by the plan in a cool and calm manner;
  4. Appeal within the time limits;
  5. Present every piece of evidence that helps your claim – don’t hold anything back for “later.” This is not a time to play Perry Mason (remember him?)

If you’ve been denied valid benefits that are subject to ERISA, contact an attorney whose practice focuses in this area of the law. Consultations are free, without obligation and are strictly confidential. To contact a qualified attorney to discuss your situation, please click here. We may be able to help.