ERISA Claims

The Employee Retirement Income Security Act (ERISA) is a federal law that governs most employer-sponsored benefit plans, including long-term disability, life insurance, and retirement plans. If your claim is denied, federal law requires you to exhaust the administrative appeals process before filing a lawsuit. An experienced ERISA attorney can help you build a strong record and protect your rights at every stage.

We established Roberts Disability Law, P.C. to help clients prove their entitlement to employer-provided benefits. We understand the importance of these benefits in providing the compensation our clients need to meet their basic life needs. We also understand ERISA’s complex rules and regulations. By remaining on the front line of developments in ERISA, we provide our clients throughout the San Francisco Bay Area with the quality representation they need to get through challenging situations.

What Is ERISA?

ERISA stands for the Employee Retirement Income Security Act of 1974. This law covers claims related to most employer-provided pension, severance, and health and welfare benefit plans. Common health and welfare benefit plans include those providing disability, life, and accidental death and dismemberment benefits. Large employers may “self-fund” these benefit plans, but many plan benefits are usually paid with insurance policy funds. ERISA typically applies to benefit plans established by private sector employers and does not apply to plans offered by a church or government entity.

How Does ERISA Impact My Benefits Claim?

When ERISA governs your claim for benefits, it preempts all other state laws. In other words, the only rights and remedies that you are entitled to receive are those that the courts have determined are available under ERISA.  Although this area of the law is always changing, the rights and remedies available to the average ERISA plan participant are generally limited. Under ERISA, insurance carriers or benefit plan administrators decide whether you meet the requirements for benefits based on the terms set forth in the insurance policy or benefit plan document. If the company denies your claim, you cannot file a lawsuit until you have exhausted your administrative remedies. This means that you have to submit a request for review (or appeal) to the administrator in order to get it to overturn the claim denial. Only when the carrier has issued a “final denial” can you file a lawsuit for benefits. And a court is typically limited to the claims record that exists at the time of the final denial. It is important for you to have the representation of a knowledgeable ERISA attorney at the time the carrier first denies your claim.

How the ERISA Claims Process Works

ERISA sets specific rules about how claims must be filed, reviewed, and appealed. One of the most important: you cannot file a lawsuit until you have exhausted all administrative remedies. This means you must appeal the denial to the plan administrator before a court can hear your case. Courts are also generally limited to the record that existed at the time of the final denial, which is why building a complete and compelling record from the start is so important.

Here is a general overview of the process:

• File your initial claim: Submit your claim for benefits along with all supporting documentation, including medical records, physician statements, and any other evidence required under your plan.
• Receive the insurer’s decision: The plan administrator reviews your claim and issues a decision. If denied, you will receive a written explanation outlining the reasons.
• Submit a formal appeal: ERISA requires plans to have an appeal procedure in place. You must file your appeal within the deadline specified in your denial letter. This is your opportunity to submit additional evidence and challenge the insurer’s reasoning.
• Receive the final determination: The plan administrator issues a final decision on your appeal. If the denial is upheld, you may then file a lawsuit in federal court.

Working with a knowledgeable ERISA attorney before you receive a final denial is the most effective way to protect your rights and strengthen your record for potential litigation.

Why Choose Roberts Disability Law, P.C.?

We at Roberts Disability Law, P.C. always prioritize our clients’ best interests. We take the time to learn all the details of your case to develop the best strategy to get your benefits claim paid. Because of our experience and knowledge of ERISA, we know how to get disability insurance carriers to pay claims and to build the best record for litigation if it becomes necessary. We stay up to date on the latest ERISA trends by reviewing recent decisions issued across the country and by speaking and frequently writing on matters impacting our clients.

We frequently achieve successful results against many ERISA plan administrators. Our client-centered approach has led to many positive results for our clients, as well as victories in both federal district court and in the U.S. Circuit Court of Appeals.

Who We Serve

Our clients come from all walks of life, but they share one thing in common: they are up against powerful insurance companies and need experienced legal representation. We regularly work with:

• Plan participants appealing a short- or long-term disability, life, or accidental death and dismemberment (AD&D) insurance benefit denial: You received an adverse decision and need to challenge the plan’s interpretation, calculation, or factual findings before the appeal deadline. 
• Employees with employer-sponsored disability coverage: Your long-term disability (LTD) policy was issued through a private employer and is likely governed by ERISA’s federal claims and appeals procedures, which set minimum standards for how your claim must be handled.
• Claimants who are unsure when they need legal help: You may be filing a complex initial claim or struggling to get clear answers from your insurer.

If you see yourself in any of these situations, speaking with an ERISA attorney sooner rather than later can make a real difference in the outcome.

Schedule a Consultation

A denial is not the end of the road. At Roberts Disability Law, P.C., we have helped many clients turn denials into approvals, and we are ready to review your case. Contact our team today for a consultation.

Frequently Asked Questions About ERISA Claims