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Under ERISA, you have the right to claim disability and to present arguments and evidence to your plan administrator (either your employer or the insurance company). If the plan administrator denies your ERISA claim, you have the right to appeal the administrator's decision. The steps you take in the ERISA appeals process will make all the difference in winning or losing your claim for benefits.
Experienced ERISA attorney Shawn E. McDermott has the skill to successfully represent clients who wish to file ERISA appeals in Colorado after being denied benefits. For advice specific to your case, please contact Shawn today.
After you receive the letter that announces your ERISA claim was denied, you must be given a reasonable chance to appeal the decision. The denial letter must clearly explain the deadline and procedure for appealing, and must provide you with a minimum of 180 days to submit a review request.
If you fail to file your ERISA appeal in a timely manner, you will most likely have failed to comply with plan requirements; this can result in an automatic denial of your claim. If the administrator fails to make a timely decision of the appeal, the administrator will not be automatically required to pay the denied benefits. At best, the participant (you) can argue that the insurer's failure to render a timely decision will cause a reviewing court to apply a more flexible standard of review.
If a client seeks legal help after submitting an ERISA appeal on his or her own, the client and his or her attorney should request an additional appeal opportunity — even if the denial was upheld. An additional appeal might be granted. In limited circumstances, the applicable policy may even provide the claimant with more than one appeal.
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The appeal from the denial letter is the most critical stage of the entire ERISA appeals process. It is your best shot at reversing the insurer's denial. This is because a court's subsequent review of an ERISA-governed long-term disability claim will be limited to the administrative record (or "claim file") developed by the administrator-insurer. Such an administrative record is typically created long before litigation begins.
After the internal appeal is completed and a lawsuit is filed, a claimant will almost certainly be prevented from submitting additional evidence in support of the claim for benefits. Therefore, the claimant and his or her attorney must understand the importance of the pre-litigation steps that must be taken to increase the odds of success.
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During the ERISA appeals process, you should take the opportunity afforded by the administrative appeal to load the claim file with as much evidence in favor of your disability as possible. Doing so will provide the plan administrator with the grounds to pay the long-term disability benefits you claimed. More importantly, this may be your only chance to submit such evidence, because it is not likely that evidence concerning disability will be accepted after the appeal has been exhausted and you have filed suit.
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In the course of developing the administrative record, the claimant's attorney should:
An experienced ERISA appeals attorney is best equipped to follow these steps and build up a strong case on your behalf. If you wish to learn more about filing ERISA appeals in Colorado, please contact Shawn E. McDermott, who can guide you through the complex procedures of filing ERISA appeals.
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Successful ERISA appeals in Colorado generally include a detailed letter from the claimant's attorney to the claims representative.
When writing your ERISA appeal letter, make sure it points out all of the following that are relevant:
The ERISA appeal letter should address all evidence not reviewed by the insurer and its importance to the determination of disability. Bias by the insurer that could be relevant might include the deliberate mischaracterization of medical evidence, mischaracterization of conversations with the claimant, an improper vocational assessment, or an improper or incomplete medical assessment. A reviewing court will likely apply a highly deferential standard of review in favor of the insurance company, requiring that a claim denial be overturned only if the insurer's conduct is "arbitrary or capricious." Thus, if there is any evidence in support of such conduct, it should be submitted during the appeal.
The claimant's attorney must take the opportunity of the appeal to load the claim file with any and all favorable evidence at their disposal. Importantly, the rules of evidence do not apply to the information and documents submitted to the insurer as part of this appeal process. Practitioners should note that the evidence in the appeal is not only addressed to the claims manager at this stage, but also to the trial court judge if the appeal is unsuccessful.
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ERISA appeals must be decided by the insurance company within 45 days. The insurer may request a 45-day extension for reasons beyond control of the plan, as long as notice is provided to the claimant.
One cannot overstate the importance of this two-step process. Unless you complete this appeal, you have no right to bring a lawsuit. More importantly, your claim and appeal had better be done well, because courts generally give significant deference to plan administrative decisions. If the plan's administrator decides you are not entitled to ERISA disability benefits or a medical procedure, the court will uphold that decision unless it was arbitrary and capricious or an abuse of the administrator's discretion. This standard means that if the administrator has substantial evidence supporting its denial, you cannot win — even if you have more and better evidence. So, if you do not win your ERISA appeal, you might have little chance to win in court.
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Many people lose their ERISA benefits because they don't do everything they can to prove their case during the two-step ERISA administrative appeals process.
Typically, the plan's administrator will not help you, even though the administrator is supposedly your fiduciary. In today's corporate environment, it is rare that plan administrators will go the extra mile to help an employee file an ERISA claim or an ERISA appeal. Instead, these "fiduciaries" sometimes go out of their way to make sure that the employee does not receive benefits. They may pretend not to receive medical records, deny claims without specifying a reason why and hope the claimant will simply give up, or even interfere with the claimant's doctors. Some administrators will help — but it is wise to assume that it is up to you, and your attorney, to prove your claim.
Hiring an experienced ERISA attorney can make all the difference in the success of your ERISA appeals process. Located in Denver, Colorado, Shawn McDermott is one of the state's foremost attorneys in this area of law. Contact him today for a review of your case.
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To learn more about the terms and laws that govern ERISA litigation and appeals, please explore the following pages:
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If you are thinking of pursuing the ERISA appeals process, you can vastly increase your chances of success by working with a lawyer experienced in this area of the law. Insurance litigator Shawn E. McDermott has handled many ERISA appeals in Colorado and is one of the state's foremost ERISA lawyers. Contact Denver ERISA attorney Shawn E. McDermott today for an honest assessment of your case.
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To learn more about filing ERISA appeals in Colorado, contact experienced ERISA attorney Shawn E. McDermott today.
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Shawn McDermott is also Of Counsel to the McDermott Law Firm in Canon City, which is owned and operated by John A. McDermott.