ERISA Disability Insurance Denials: How to Challenge an Unfair Decision

The Employee Retirement Income Security Act (ERISA) governs most employer-sponsored disability insurance plans and provides guidelines for claims and appeals. While ERISA is meant to protect employees, it often benefits insurance companies, making it difficult for claimants to receive the benefits they deserve. If your ERISA disability insurance claim has been denied, understanding your rights and the appeals process is crucial.

Here’s what our nationwide claims attorneys at Disability Insurance Law Group want you to know about challenging an unfair ERISA disability insurance denial.

Why Are ERISA Disability Insurance Claims Denied?

Insurance companies deny disability claims for many reasons, often using broad or vague justifications.

Some of the most common reasons include:

• Lack of Sufficient Medical Evidence – The insurer may claim that your medical records do not support a disabling condition.
• Failure to Meet the Definition of Disability – Many ERISA policies have strict definitions of “disability,” such as distinguishing between “own occupation” and “any occupation” disabilities.
• Pre-Existing Condition Exclusions – Some claims are denied because the insurer believes the disability existed before coverage began.
• Missed Deadlines – ERISA policies have strict deadlines for filing claims and appeals. Missing any deadline can result in an automatic denial.
• Surveillance or Social Media Monitoring – Insurers may use surveillance footage or social media activity to argue that a claimant is not as disabled as they claim.

How to Challenge an ERISA Disability Insurance Denial

If your claim is denied, you have the right to appeal, but ERISA’s complex rules require a strategic approach.

Here’s how you can fight back:

• Request and Review the Denial Letter

ERISA requires insurers to provide a written explanation for the denial. Carefully review this letter to understand the specific reasons your claim was denied and identify any missing or insufficient documentation.

• Obtain a Copy of Your Claim File

You have the legal right to request your entire claim file, which includes medical records, internal notes, and reports used by the insurance company. This file can explain why your claim was denied and help you build a stronger appeal.

• Strengthen Your Medical Evidence

Medical documentation is critical in an ERISA disability appeal.

Consider:

• Obtaining detailed statements from your treating physicians.
• Undergoing additional medical testing to provide objective evidence.
• Submitting functional capacity evaluations (FCEs) or vocational assessments to demonstrate work limitations.

Insurers will find reasons to deny your claim without clear, detailed, and properly submitted medical documentation. At Disability Insurance Law Group, we know how to present compelling medical evidence to strengthen your case and fight for the benefits you deserve.

• Address Any Insurance Company Tactics

If the insurer used surveillance, independent medical exams (IMEs), or biased doctor reviews to justify the denial, counter their findings with more substantial medical evidence and expert opinions.

• File a Strong Administrative Appeal

ERISA requires claimants to go through the insurance company’s internal appeals process before filing a lawsuit.

Your appeal should be comprehensive and include:

• A detailed rebuttal of the insurer’s reasons for denial.
• Additional medical and vocational evidence.
• Personal statements and supporting testimony from family, colleagues, or caregivers.

Working with an experienced ERISA disability attorney to ensure your appeal is thorough can help move your claim in the right direction. Remember, the administrative appeal is your last chance to submit new evidence before litigation.

• Consider Legal Action if Your Appeal is Denied

If the insurer upholds the denial after the internal appeal, you can file a lawsuit in federal court under ERISA regulations. Litigation is complex, as courts often defer to the insurer’s decision unless it is proven to be “arbitrary and capricious.”

Having a skilled disability insurance attorney can significantly improve your chances of success.

Why You Need a Disability Insurance Attorney

ERISA laws are highly technical, and a simple mistake can cost you your benefits.

A disability insurance attorney can:

• Navigate ERISA regulations and deadlines.
• Gather the right medical and vocational evidence.
• Challenge unfair insurance company tactics.
• Represent you in litigation if necessary.

At Disability Insurance Law Group, we fight for claimants nationwide who have been unfairly denied disability benefits. If your ERISA disability claim has been denied, contact us today at 954-989-9000 or online for a free consultation to discuss your options.

Don’t let an insurance company control your future—fight for the benefits you deserve.

Related Links

• Long-Term Disability Delayed & Denied Insurance Claims Attorneys
• The Importance of Proper Documentation in Disability Claims: What Evidence Do You Need?
• How to Handle Delays in Long-Term Care Insurance Claim Processing
• Unfair Disability Insurance Claim Denials: How to Take Legal Action Against Your Insure