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Reasons why ERISA disability claims are denied

On Behalf of | Jan 22, 2021 | Disability Benefits |

If you suffer a devastating long-term or permanent injury at work, it’s crucial to you and your family’s well-being that you receive the disability benefits you deserve. However, insurance companies make that as difficult as possible as their priority is to protect the bottom line, paying as little as possible or nothing at all.

But protections for workers are in place. The Employee Retirement Income Security Act of 1974, commonly known as ERISA, safeguards benefits and sets standards for insurers administering these plans. ERISA sets requirements for processing claims, deadlines for decisions and outlines your rights after a denial.

Common reasons for ERISA denials

ERISA claims are frequently rejected – many that would be approved under Social Security disability or other private insurance guidelines. Some of the reasons given include:

  • There’s no evidence the disability exists
  • The claimant missed the deadline to file
  • The form was not filled out correctly
  • Pre-existing medical conditions
  • Unauthorized treatment
  • Self-reported symptoms not confirmed by a doctor
  • Policy exclusions
  • The claimant can work

In addition, denials also result when investigators allege a claim is false or social media posts provide contradictory evidence.

ERISA appeals can be challenging

For years, ERISA rules have tilted toward insurers, who could deny claims for practically any reason without a great deal of explanation. Most denials were neither transparent nor were insurers held accountable for decisions. Lawsuits over denials must meet high standards and prove that an insurance company’s decision was “arbitrary and capricious.”

However, in 2018, the U.S. Labor Department adopted new rules ordering insurers to provide specific reasons for denials, instead of generic rulings stating that the claim didn’t “meet their criteria.” Insurers must detail why they disagree with a doctor’s determination, outline the specific rules and procedures for making a decision and supply you with all relevant documentation upon request.

Navigating the ERISA claim and appeal process

ERISA claims are complicated, and even minor mistakes can lead to denials. That’s why it’s advisable to work with an experienced ERISA attorney who understands how the process works, how to fill out the paperwork correctly and how to successfully overturn denials or terminations.

Suffering a disabling injury can lead to permanent physical and financial consequences. A knowledgeable lawyer will aggressively fight for the benefits you deserve to protect you and your family’s future.