The Definition of a Denied Claim—And What’s Next?

There are many reasons that claims are denied. Your Notice of Denial letter from the insurer should spell out clearly why you were denied benefits. ERISA has set out requirements of what must be included in your Notice of Denial, including:

Denied stamp for an ERISA claim
  • The specific reasons for your denial.
  • The plan provision relied on for denying you benefits.
  • Any steps you must take to perfect your claim for benefits.
  • The deadline for bringing an appeal.
  • A description of the plan’s procedure for reviewing a denial.
  • How medical information was used, if a denial was based on medical judgment.

Administrative exhaustion

Although you might want to run off to court and file a lawsuit, you need to be aware of an important concept in ERISA litigation: exhaustion of administrative remedies. Basically, this means that you will need to pursue all administrative appeals and other relief before you head off to court and file a lawsuit.

Administrative exhaustion plays an important role in ERISA and prevents the courts from becoming overwhelmed with disputes about whether a health insurance plan will cover a certain procedure. However, this principle does not mean that you must bring endless administrative appeals.

Indeed, ERISA requires a “reasonable procedure,” which should probably not be more than two mandatory administrative appeals. Any more than that is probably illegal under ERISA, though voluntary administrative appeals might be allowed.

There is an important limitation on administrative exhaustion that came into play in 2018. Namely, you will be able to sue your insurer before exhausting all administrative appeals if the insurer did not comply with the required claims procedures. This is a powerful tool to keep an insurer in line so that it does not violate your rights throughout the entire claims process.

Whenever you bring an administrative appeal, you need to keep an eye on how the information you submit can help or hinder an ultimate appeal in court. This requires extensive planning and familiarity with the entire appeal process, administrative or judicial.

Speak to an Experienced Attorney Today

To begin building your strongest appeal possible, you should meet with an experienced ERISA attorney soon after receiving your Notice of Denial. At Peace Law Firm, we help workers obtain the benefits they are entitled to under the specific terms of their plans. We have helped countless clients and are anxious to work with you, also.

You should realize that you are not in this alone. After being denied badly-needed benefits, many of our clients express fear of the future, but please recognize that seasoned legal help is available. At our firm, we have been practicing ERISA laws for decades. We stay on top of each change in the law and thoroughly investigate how the rules can benefit you, our client.

If you are interested in finding out more, please contact us today. We offer a free initial consultation where you can ask any question you want about the appeals process or our experience. We will also analyze the circumstances to see whether you have a legitimate reason to bring an appeal.

Contact us today by calling or sending an online message.