Denver ERISA Disability Claims Lawyer

Denver ERISA Disability Claims Attorney

The Colorado ERISA attorneys at McDermott Law are some of the very few lawyers in the region whom disabled individuals can turn to in their fight against an ERISA disability or life insurance benefits claim denial. If you have experienced a denial of your short-term or long-term disability claim, or other benefits denial, you need to know your rights and responsibilities. This is a crucial time for those fighting to obtain their disability insurance benefits.

We can assist you with your required appeal of the denial. If the appeal of the adverse benefit determination is unsuccessful, we can file a lawsuit on your behalf. The disability insurance attorneys at McDermott Law have a proven record of success in these matters. We urge you not to wait to contact an attorney if your claim has been denied. Early involvement of an attorney in the claim and internal review process will significantly improve your chances of receiving the disability benefits to which you are entitled.

What Are ERISA Disability/Health/Life Insurance Claims?

In 1974, the Employee Retirement Income Security Act (ERISA) was passed to ensure that pension and health plans meet certain standards according to federal law. As such, if you are an employee in the United States, it is most likely that your employee benefits are controlled by the ERISA laws and regulations.

It often takes a lawyer a very long time to learn the nuances of ERISA law. The law is not clear, and more importantly, it is not necessarily fair. If you have been denied benefits (whether they are covered by ERISA or not), we may be able to help you.

What Is Involved With An ERISA Claim?

It is typical for an insurance company to delay or deny an individual’s ERISA long-term disability claim. There are many factors that may result in a person being denied ERISA benefits by an insurance company, such as improper filing of documentation and the type and severity of the injury. In the event that your long-term disability claim was denied, you will have a period of time (180 days is now mandated) to request a review of your ERISA claim denial. In this time, you may have to file a variety of documents, which must be accurately filled out and filed in a timely manner. You may be required to submit further personal information or evidence to prove that you are eligible and entitled to the benefits that you were denied.

Why Is It Important To Hire An Experienced ERISA Attorney?

People filing ERISA disability and health insurance claims in Colorado are often at a difficult crossroads in their lives. You might be facing the permanent lowering of your standard of living. You might be dealing with the end of a career that you loved or might be coming to grips with major health problems. You might be seriously depressed. You should never be embarrassed that you might need help or that you are having to deal with powerful emotions. So get the help you need by taking positive steps, including hiring an ERISA attorney you can trust.

The legal process that is involved in ERISA disability claims is very complex, and requires the experience and knowledge of a disability claim attorney who has successfully represented clients in ERISA disability claims and ERISA appeals cases.

Learn More About ERISA

If you are involved in a dispute related to ERISA health insurance or disability claims, it helps to be armed with some knowledge about the law. For useful information prepared by our expert ERISA attorney in Denver, please consult the following pages:

• ERISA overview and relevant terminology
• Appealing ERISA claim decisions
• ERISA long-term disability litigation
• Article by Shawn E. McDermott in The Colorado Lawyer (published May 2004)

If Your ERISA Claim Is Denied In Colorado, We Can Help

If your disability, life, health or AD&D benefits are provided through a plan established by your employer, then your claim is most likely governed by a federal law known as the Employee Retirement Income Security Act of 1974 (a.k.a.”ERISA”). If so, this federal law applies to your claim, and not the law of your state. 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.

The experienced Denver ERISA attorneys at McDermott Law, LLC, have a proven track record of successfully representing clients who need to pursue their internal ERISA appeals after being denied benefits. The insurance company has not told you this: the appeal of the disability denial you have received is, by far, the most important stage of the entire process for obtaining your long-term disability benefits. You must take this step in the process very seriously.

Important Deadlines

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, the 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.

Bringing An Administrative Appeal

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.

Gathering Evidence Of Your Disability

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.

Developing An Administrative Record

In the course of developing the administrative record, the claimant’s attorney should:

• Immediately request the claim file
• Request copies of the plan, the summary plan description and a copy of the policy
• Obtain additional opinion letters from treating physicians
• Provide pertinent medical literature that better explains the nature of the disability to the claims representative (and ultimately to the judge)
• Provide documentation from co-workers, the employer, and friends and relatives concerning the claimant’s disability
• “Humanize” the record so it will document the impact of the claim on a real person’s life. These records should be submitted to the claims representative, within the appeal deadline (180 days from the denial), along with a comprehensive letter from counsel.

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 our ERISA appeals lawyers at McDermott Law, LLC. We can guide you through the complex procedure of filing an ERISA appeal. The claimant’s attorney must take the opportunity of the appeal to load the insurance company’s claim file with any and all favorable evidence at his or her 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. 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 Appeal’s Outcome

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.

Avoiding Pitfalls

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, we at McDermott Law are considered by many as the state’s foremost attorneys in this area of law.

Begin Your ERISA Appeal

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. The ERISA appeals and litigation lawyers at McDermott Law, LLC, have handled literally hundreds of ERISA appeals in Colorado. We are one of the state’s foremost ERISA law firms. To contact our Denver ERISA attorneys for a free Review of Denied Claims, complete our contact form or call 303-964-1800. We can help.

Fighting For Your ERISA Claim In and Out Of The Courtroom

After their ERISA administrative appeal is denied, some people elect to pursue litigation to recover their ERISA long-term disability benefits. At McDermott Law, our insurance law attorneys have helped clients throughout Colorado successfully pursue ERISA litigation. We have prepared this list of general guidelines to introduce you to your rights under the law; however, nothing can replace the one-on-one advice of an experienced ERISA attorney.

Disability Statistics

The risk of disability may be greater than you think. Recent statistics have shown:

• On the average, about 2,340 disabling injuries occur every hour during the year (National Safety Council, Injury Facts, 2001).
• About 30% of Americans from ages 35 to 65 will suffer a disability for at least 90 days (Health Insurance Association of America, The New York Times, February 2000).
• About one in seven Americans can expect to become disabled for five or more years (Health Insurance Association of America, The New York Times, February 2000).

Short-term and long-term disability insurance is intended as a solution if you become sick and cannot work. Do not let your insurance company deny you your rightful claim to these benefits.

Guidelines On ERISA Long-Term Disability Litigation

Before beginning ERISA long-term disability litigation, it helps to be familiar with a few of the regulations that govern such suits:

• You have the right to sue for benefits in state court or federal court, although the judge will “remove” your case to federal court, if you file in state court.
• Your lawsuit is a claim for ERISA benefits that were wrongfully denied. You are only entitled to recover the amount of the past-due benefits and, usually, interest on the withheld benefits. You cannot make a claim for bad faith breach of insurance contract as it is typically asserted in cases not governed by ERISA.
• If your ERISA litigation is successful, your attorney’s fees might be awarded to you by the court.
• You are not entitled to a jury trial. A judge will make all determinations.
• Regardless of the insurance company’s conduct in denying your ERISA long-term disability claim, you are not entitled to punitive damages, nor damages for pain and suffering.
• One of the most critical issues is what standard of review the courts will apply. In ERISA litigation, it is necessary for the parties to agree on, or the court to determine, which standard of review the court will apply to the claim administrator’s decision to deny ERISA long-term disability or another type of benefits. There are two types of review a court may use, depending on the language found in the plan document: (1) de novo, in which no weight is given to the administrator’s decision; and (2) abuse of discretion (also called “arbitrary and capricious”). In this context, the Tenth Circuit Court of Appeals treats the terms “abuse of discretion” and “arbitrary and capricious” as interchangeable.
• Even if the plan gives the administrator discretion, the court will apply a less deferential review if it can be proven that the administrator is working under a conflict of interest.
• You should assume you cannot add any evidence to the administrative record during the course of litigation. The most crucial step in your claim is properly submitting an administrative appeal.

Begin Your ERISA Long-Term Disability Claim

ERISA long-term disability is a specialized area of the law governed by many complex rules. At McDermott Law, our ERISA attorneys assist applicants with all aspects of filing ERISA claims and appeals. We also specialize in the handling of plaintiffs’ ERISA benefits litigation and have done so hundreds of times. You likely will not find more experienced attorneys in Colorado in this area of the law.

Contact Us

If your ERISA benefits appeal has been denied and you are considering pursuing litigation in court, please contact our ERISA attorneys today for an honest review of your case. To set up a free Review of Denied Claims, call 303-964-1800 or complete our contact form. We have helped thousands of people throughout Colorado and the Rocky Mountain region get the insurance coverage they need and deserve.

Helping You Navigate ERISA

Based in Denver, Colorado, the ERISA lawyers at McDermott Law, LLC, have prepared this overview of ERISA (the Employee Retirement Income Security Act), which governs employee benefits in Colorado, including health insurance and long-term disability claims. Though this page is designed to give consumers a thorough overview of ERISA and its limitations, nothing can replace the advice of an experienced ERISA lawyer.

What Is ERISA?

The Employee Retirement Income Security Act (ERISA) was passed by the U.S. Congress in 1974 to regulate employee benefits such as health benefits, disability benefits, vacation benefits and more. Most people who participate in a pension or group insurance plan through a private employer or employee organization are covered by ERISA. Unfortunately, many employers ignore the laws that govern employee benefits. They may violate their workers’ rights or take advantage of employees, who don’t know all of their rights.

What Does ERISA Regulate?

ERISA regulates employee benefit plans. These plans exist in two forms: (1) “employee pension benefit plans;” and (2) “employee welfare benefit plans,” which are established and maintained to provide health benefits, disability benefits, death or unemployment benefits, prepaid legal services, vacation benefits, day care centers, scholarship funds, apprenticeship and training benefits and other similar benefits.

When ERISA was first adopted, the legislation was hailed as a major success in advancing employee interests, at least in relation to overhauling the private pension industry. However, in the 30 years, ERISA has been in effect, many would argue that it has become better known as a shield against consumer interests in the administration of nonpension employee benefit plans, such as long-term disability benefits. ERISA is frequently used by the plan or insurer to prevent employees from having the legal redress they would have had under pre-ERISA state laws.

To complicate matters, a review of the ERISA statutes rarely provides a complete answer to a specific question. Further, the circuit courts are divided on the interpretation of important issues, including the standard of review, the scope of discovery and the admissibility of evidence.

To learn more about what ERISA regulates and the process of recovering ERISA benefits, please contact Denver, Colorado, ERISA lawyer Shawn E. McDermott.

Key ERISA Terms

It is essential to have a working knowledge of technical definitions of important ERISA terms. Some commonly used terms are:

• Group policy: If long-term disability (LTD) benefits provided by the employee benefit plan are insured by the plan sponsor, the insurer issues a group insurance policy.
• Pension benefits: These benefits consist of payments to retirees, based in part on years of service.
• Plan administrator: According to most courts, this is the company or person responsible for making the decision to deny or pay benefits. Typically, the plan administrator is the insurance company issuing the LTD group policy if the plan is insured.
• Plan document: All of the plan’s rules and terms are spelled out in the complete employee benefit plan document. Often, the “plan” is the insurance policy itself. (See also the definition of “summary plan description” below.)
• Plan participant: Typically, this refers to the employee enrolled in the plan. The plan participant also may be referred to as the claimant or the insured.
• Plan sponsor: The employer or a union providing the plan
• Summary plan description: Explains the available benefits, claim procedures, permissible benefit offsets, how and when benefits are payable, and how to appeal should the benefits are denied. The information often is provided in an employee benefits booklet.
• Welfare benefits: These benefits include any benefit that is not a pension benefit, such as disability, health or life insurance, prepaid legal services, or nonmonetary benefits, such as daycare services.

If you have a question about an ERISA term not included on this list, or another aspect of ERISA health or disability insurance law, please contact Denver, Colorado, ERISA lawyers at McDermott Law.

Elements of Plans Governed By ERISA

Most private-sector employee benefit plans are governed by ERISA. Nonetheless, it is incumbent on an employee to verify that this is truly the case. The purchase of an insurance policy by an employer does not automatically establish the existence of an ERISA plan. If the plan benefit is insured and the claimant questions the applicability of ERISA, the insurer has the obligation of establishing that federal law under ERISA governs the insurance policy.

The threshold issue in determining whether the court has jurisdiction pursuant to ERISA is whether the employee’s claim relates to insurance coverage he or she obtained it through an “employee welfare benefit plan.” By statute, there are five elements that must be met to constitute an employee welfare benefit plan. The plan must be (1) a plan, fund or program (2) established or maintained (3) by an employer, employee-organization, or both (4) for the purpose of providing medical, surgical, hospital care, sickness, accident and other benefits (5) to participants or beneficiaries. If all elements are satisfied, the plan is governed by ERISA rather than state common law.

Plans Not Covered By ERISA

Several kinds of plans are not governed by ERISA. These include: (1) group plans established or maintained by governmental entities or churches for their employees; (2) plans that are maintained solely to comply with applicable unemployment, or disability laws; (3) plans maintained outside the United States primarily for the benefit of nonresident aliens; and (4) unfunded excess benefit plans.

“Safe Harbor” Regulations

In addition, there is a “safe harbor” that may exempt an established plan from ERISA. U.S. Department of Labor regulations provide that ERISA does not apply to group or group-type insurance programs where:

• No contributions are made by an employer or employee organization.
• Participation in the program is voluntary.
• The sole function of the employer is to permit the insurer to advertise the program to employees, and the employer only collects premiums through payroll deductions for the insurer.
• The employer does not profit from the administration of the plan.

If the insurance program meets the criteria set forth in the safe harbor regulations, or the benefit plan is otherwise not deemed an employee benefits plan, ERISA does not apply and state law governs.

Contact The ERISA Claim Lawyers At McDermott Law, LLC

McDermott Law is one of the very few law firms in Colorado equipped to handle all aspects of an ERISA claim, the appeal and any necessary litigation. We can familiarize you with the law that applies to your case and give you an honest case evaluation. If you have questions about ERISA or have a dispute relating to ERISA benefits, please call 303-964-1800 or complete our contact form to arrange a free Review of Denied Claims. Our Colorado ERISA attorneys are ready to help you get the benefits you need and deserve.

Begin Your Claim – Contact Our ERISA Attorneys in Denver, CO

If you or a loved one is involved in an ERISA dispute, we can help. Our skilled attorneys have handled thousands of ERISA disability/health insurance claims for people throughout Denver and the Rocky Mountain region. Call 303-964-1800 or complete our contact form. We can navigate this complex area of the law, file your documents and begin litigation, if necessary.