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Claim Denials, Terminations & Appeals

What Is Your Next Step After an ERISA Claim Denial?

Most people are familiar with making employment-related insurance claims for health care benefits. You sign up for a health plan. The insurance company mails you a card. Premiums are deducted from your check. You present your insurance card when you need to see a physician, make a co-payment and most everything else is taken care of (i.e., the claim is paid) without much thought or effort on your part.

But if you need to file a high-value claim involving long-term disability or life insurance benefits in particular, the process is not so easy. In fact, claim denials are common simply because under ERISA, an insurer cannot be sued for punitive or emotional distress damages. At worst, they will have to put you on claim and pay the benefits you deserved in the first place.

Do not accept your insurance company's claim denial at face value. Attorneys at Goldstein, Gellman, Melbostad, Harris & McSparran can help. Our firm has extensive experience helping people in the San Francisco Bay Area and Northern California with insurance claim denials that are governed by ERISA. Talk to us and find out what your rights and options are. Call 415.673.5600.

With private life or long-term disability insurance, policyholders can sue the insurance company for unfair claims practices, unfair termination of benefits or wrongful claim denial. Such a lawsuit can generally be brought in either state or federal court where normal rules of damages, evidence, discovery and civil procedure will apply.

With policies governed by ERISA, an individual whose claim is denied has no other initial option than to request an administrative review of their case. It is important to note also that this request must be filed within 180 days of the claim denial.

The administrative appeal itself is limited to a review of the evidence and medical documentation contained in the record. In most cases, subsequent federal lawsuits and appeals will also be limited to a review of the case file only. Because of this, the sooner our lawyers can get started on the process of reviewing what has happened thus far and on making certain that all necessary evidence and information is contained in the file before the administrative appeal moves forward, the better.

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We offer free initial consultations and can provide advice and representation on either an hourly basis or on a contingency basis. To learn more, call our offices directly at 415.673.5600 or contact us online.

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