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The Employee Retirement & Income Security Act of 1974 (commonly called “ERISA”) applies to employee benefits, like health insurance, life insurance, disability insurance, 401(k)’s, pensions, and others.

If you have a beef with those benefits, ERISA applies. Unfortunately, a lot of people have beefs, because insurance companies regularly deny benefits. Some of those denials are justified, but many are not.

Compounding the problem, many people decide to handle the appeal themselves, rather than seeking legal advice. That is, more often than not, a mistake. ERISA claims are complex traps for the unwary.

If you are in this situation and have been denied benefits—or think you might be—here are 4 reasons you should consider seeking an experienced ERISA lawyer.

1. If you lose, your options are limited.

ERISA allows you to sue for a handful of things, and that’s it. You can sue to enforce your rights under ERISA or your plan, to recover benefits you are entitled to, for civil penalties, and for other “appropriate equitable relief.”

What about punitive damages? Nope. What about state law claims, like fraud, misrepresentation, or breach of contract? Nope. These state law claims and remedies are out-of-bounds when it comes to your employee benefits.  

That is because ERISA trumps (or “preempts”) all state law claims. Some insurance regulations might still apply, but that’s it. So if you think you’ll be able to just sue for whatever you want if your denial is upheld, think again.

2. If you have to sue, the insurance company gets special treatment.

Again, this is not an ordinary lawsuit. Normally, a jury (or at least a judge) would review the facts and decide on their own if you are entitled to benefits. Simple.

Not so much in ERISA. Here, there are no juries. Instead, there is only a judge. And the judge doesn’t get to decide on his own if you should get your benefits. Instead, the judge only gets to decide if the insurance company’s denial was unreasonable.

In other words, the judge presumes the insurance company was right, and you have to prove they were wrong. And not just wrong, but completely unreasonable; if there is any reasonable basis supporting the insurance company’s denial, it will be upheld.

As you can imagine, this is tough. So you at least better make sure you have all the evidence you need.   

3. If you don’t submit the right evidence, you can’t fix it later.

You might also think that, even if your appeal is denied, you or your attorney will at least be able to submit new evidence for the judge to see. And again, you’d be wrong. The problem here lies in the fact that the judge must give your insurance company special treatment.

So if the insurance company didn’t get to look at your evidence before the final denial was made, then neither can the judge. He or she will tell you the evidence should have been submitted sooner. It typically doesn’t matter how strong the evidence is. If you didn’t follow the rules, there is little hope of getting around them.

4. You need legal expertise to know your plan and make the right arguments.

Insurance contracts are not exactly light reading. They are long, complex, and require legal expertise to understand. Odds are, only an attorney will be able to figure out what, exactly, your plan is, and what, exactly, it requires of you.

Only then can you begin to make the right arguments to the insurance company. And, sometimes, the right argument can convince the insurance company to pay your benefits now, without having to resort to a lawsuit.

So there you have it. If you have been or think you might be denied benefits under an ERISA plan, it is a good idea to consult a lawyer experienced in ERISA law. There are a lot of mistakes that can be made, and if you try to handle the appeal yourself, you might end up damaging your case beyond repair.

Phil Tatlow has been representing individuals in ERISA appeals for many years. If you think you might need an ERISA attorney, please contact us for a free consultation.

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