ERISA Appeal Process in South Carolina
Please note: The Peace Law Firm is licensed to practice only in North Carolina and South Carolina.
If you’ve ever filed an ERISA claim, you know that the wait to hear whether your claim has been approved or denied can be challenging.
Will they approve your claim for benefits?
Will you need to provide more information?
You may wait months to hear about the status of your claim, only to have it rejected.
What happens now?
The most important way to assert your rights and collect the benefits you deserve is to file an ERISA appeal. This blog post will explain what South Carolinians should know about the ERISA appeal process. We’ll cover the purpose of these appeals, the process, and how you can increase your chances of receiving benefits.
Ultimately, the best way to file an ERISA appeal is to have an experienced ERISA lawyer as your guide. John Peace and the Peace Law Firm have spent years helping claimants in South Carolina successfully appeal ERISA denials and access the benefits they deserve.
Contact us online or call (864) 298-0500 today to get started.
What Is an ERISA Appeal?
An ERISA appeal is a formal request to reconsider a denied benefit claim. The Employee Retirement Income Security Act (ERISA) is a federal law that governs most employer-sponsored benefit plans, including disability, life, and health insurance plans. It also regulates employer-provided pension and retirement plans.
When a plan administrator denies a claim, they must provide a written explanation of the denial and inform you of your right to appeal. The ERISA appeal process allows you to submit additional evidence and arguments to support your claim for benefits.
Why File an ERISA Appeal?
An ERISA appeal serves two primary purposes: it provides an opportunity to overturn a denial and helps build a record for potential legal action.
Establishing Facts to Overturn a Denial
First, the ERISA appeals process is a way to supplement the factual record of your claim with additional evidence that supports your case.
An appeal allows you to submit additional medical records, expert opinions, and supporting documentation to strengthen your case. Many claims are initially denied due to insufficient evidence, and a strong appeal can reverse that decision.
Gathering Important Information for Future Action
If you believe plan administrators violated your legal rights with a denial, you may be able to file a lawsuit if your appeal is unsuccessful. However, courts considering ERISA claims rarely allow you to submit additional evidence beyond what’s already in the administrative record.
Therefore, it’s crucial to take the opportunity during an appeal to collect as much information as possible about the plan administrator’s decision-making process.
Although ERISA appeals do not have a traditional discovery process, you do have the right to request relevant claim documents, including records, guidelines, and policies relied upon in denying your claim.
If you think that you may need to challenge the denial of a claim through an ERISA appeal, it is important to speak to an experienced ERISA attorney. The ERISA appeal process can be complex, and the Peace Law Firm can help you navigate it.
Who Can File an ERISA Appeal?
Any plan participant or beneficiary whose claim for benefits has been denied under an ERISA-governed plan can file an appeal. This includes employees covered under an employer-sponsored insurance or retirement plan and their eligible dependents.
Peace Law Firm has nearly 20 years of experience representing individuals like you in ERISA appeals. We can help you fight for the benefits you deserve and guide you through the ERISA appeal process.
How Do You File an ERISA Appeal?
To file an ERISA appeal, you need to follow the ERISA appeal procedure of your benefit plan. Usually, the plan will tell you what the appeal process is for your claim. You’ll typically be notified of this when they send you notice of the denial of your claim.
Make sure that your insurance company has your most up-to-date contact information. You do not want to miss any important deadlines! If your plan does not provide you with notice of their appeal process, you should request a copy.
It is very important for you to understand what the timelines are for filing your appeal. Typically, plans provide you with either 60 or 180 days from the date of your denial letter to file your appeal. You are typically entitled to only one appeal once your claim is denied.
If you decide to go through the ERISA appeal process, hiring an experienced ERISA appeals attorney is essential to your success. The process can be very complicated, and our lawyers at Peace Law Firm can help you successfully file your appeal. That’s the first step in helping you get what you deserve!
Common Mistakes When Filing an ERISA Appeal
The ERISA appeal process is time-sensitive and can be complex. Many claimants make critical errors during the appeal process that can jeopardize their case. Here are some common pitfalls to avoid:
- Misunderstanding the process. Most ERISA plans allow only one appeal, meaning you must submit all relevant evidence upfront. Failing to understand the regulations and limits of the administrative appeal process can mean losing your chance to secure benefits.
- Missing deadlines. If you fail to file within the designated timeframe, you may lose your right to appeal.
- Making a verbal appeal. Some insurers allow verbal appeals, but this can waive your right to submit additional evidence. Always appeal in writing.
- Forgetting to cite policy provisions. Clearly reference your insurance policy and applicable ERISA regulations to strengthen your appeal.
- Not creating a complete record. If your appeal is denied, the record of documents and information you submitted becomes the foundation of any future lawsuit. Include all possible supporting evidence.
Avoiding these mistakes can improve your chances of success and preserve your legal options if you need to take further action.
Tips for a Successful ERISA Appeal
Following best practices can help you maximize the likelihood of a favorable outcome. Here are some key strategies to increase your chances of receiving benefits on appeal.
Make Sure You Understand the Rules Governing Your Initial Claim
Sometimes, you must look back at where you’ve been before moving forward. Before seeking relief through an ERISA appeals process, you may need to revisit the rules and facts of your original claim. Taking another look at this information can help you determine whether you were eligible for benefits and whether you followed all the guidelines to receive those benefits. If you were an eligible beneficiary who followed all the rules for making a claim, you may have a strong argument for receiving benefits on appeal.
You can find the rules for your claim in the summary plan description and any applicable summary of benefits and coverage your plan administrator gave you. Beneficiaries of ERISA plans must receive these documents when they enroll, and they must receive updates when plan rules and information change. If you no longer have your summary plan description or summary of benefits and coverage, you can request and receive copies of those documents.
The Peace Law Firm can help you review the parameters of your plan and determine whether your initial claim had any eligibility or procedural issues. If we can identify an issue with your initial claim, we can develop the best arguments for why you still should have received benefits.
Understand Why Your Claim Was Denied
Identifying the reason for denial allows you to tailor your appeal strategically. Common reasons for ERISA claim denials include:
- Lack of sufficient medical evidence,
- Failure to meet the policy’s definition of disability,
- Missing or incomplete documentation, and
- Administrative errors by the plan administrator.
Read your denial letter carefully to determine why your claim was rejected.
Determine Whether the Claim Process Was Reasonable
A benefit plan administrator may have many rules for making or maintaining a claim. An administrator may also tell you that it denied benefits because you didn’t fulfill its requirements. However, the rules for claiming and receiving benefits must be reasonable.
Under federal regulations, claim procedures or the administration of a claim can’t unduly hamper or inhibit the claim. This can happen if:
- The beneficiary must pay a fee to make a claim or file an appeal; or
- The beneficiary must obtain prior approval for benefits, and that requirement is impossible to fulfill under the circumstances (e.g., the beneficiary has a medical emergency).
Regardless of a plan administrator’s rules, the evidence you present about the circumstances of your claim might help you win benefits in your appeal.
A plan’s rules might also be unreasonable if any of the following apply:
- The plan doesn’t allow your authorized representative to seek benefits on your behalf,
- The plan provides disability benefits but doesn’t ensure the impartiality and independence of individuals making claims decisions, or
- The plan is a group health plan that requires more than two appeals before you can file a civil action.
The above-listed characteristics are just a few ways a plan can be unreasonable. The unreasonableness of an ERISA plan also depends on the type of benefits it provides. We know how to rate a plan’s reasonableness and can guide you through the process.
Submit as Much Evidence as Possible
Collecting evidence to prove your right to benefits and providing comprehensive medical documentation is crucial. Consider obtaining:
- Additional medical tests or evaluations,
- Expert opinions from treating physicians, and
- Written statements from medical providers supporting your claim.
The strength of your evidence can make or break your case, and we can help you gather the strongest proof to support your position.
Stay Ahead of Deadlines
Track all appeal deadlines carefully. Missing a deadline can result in losing your right to challenge the denial.
Document Everything
Maintain a complete record of your appeal by keeping:
- Copies of all documents submitted,
- Written communication with your insurer, and
- Proof of delivery for appeal submissions.
Detailed documentation can help protect your rights if your appeal is denied, and you must take legal action.
Can My Employer Interfere with My ERISA Appeal?
It’s illegal for employers to retaliate against employees who assert their ERISA rights, including the right to appeal. Unlawful retaliation may include:
- Job termination,
- Work suspension,
- Unwarranted disciplinary action, and
- Discrimination in the form of unequal treatment at work.
If you experience retaliation, contact an attorney immediately—you may have a separate legal claim. You may also have a separate legal claim if you are denied benefits because of an illegal motivation.
What If My Claim Is Denied for an Illegal Reason?
Unfortunately, administrators don’t always play fair when providing ERISA benefits. An administrator might deny benefits for an unlawful reason. This type of reason is usually associated with the claimant’s:
- Race,
- Genetic information,
- Gender,
- Medical history,
- Color,
- Disability,
- Age, or
- Health condition.
If you face an illegal denial of your benefits claim, you can file a complaint with the Secretary of Labor. A complaint might prompt your plan administrator to pay your benefits or offer a settlement.
A civil action to address retaliation or discrimination can require a thorough investigation of the facts or an intricate analysis of potential remedies. Fulfilling these steps is much simpler with the help of a skilled attorney. The Peace Law Firm has extensive experience getting the relief that ERISA claimants deserve.
How Long Does the Appeals Process Take?
Plan administrators generally have 45 days to decide on an appeal. However, they may extend this deadline an additional 45 days if needed.
Should I Hire a Lawyer for My ERISA Appeal?
While filing your initial claim is generally straightforward, having the assistance of dedicated ERISA appeal counsel is essential to your success in an ERISA appeal. Peace Law Firm has nearly two decades’ of experience representing individuals like you—NOT insurance companies.
We can help you understand the complex ERISA appeal process and fight for the benefits you deserve. Contact us online or call (864) 298-0500 today to request a case consultation and see how we can help you.
Resources:
- Contents of summary plan description, 29 C.F.R. § 2520.102-3 (2001), link.
- Summary of benefits and coverage and uniform glossary, 45 C.F.R. §147.200 (2016), link.
- Employee Benefits Security Administration, Participants’ Rights, link.
- Employee Benefits Security Administration, Filing a Claim for Your Health Benefits, link.
- Claims procedure, 29 CFR § 2560.503-1 (2020), link.
Prohibiting discrimination against participants and beneficiaries based on a health factor, 29 U.S.C. § 1182, link.
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