ERISA Questions and Answers

1. Should I obtain legal representation to assist me in filing an ERISA claim application?

The answer to this question depends on your confidence in your ability to complete all of the requirements under your plan to initiate a benefits claim. In many instances, the benefits at issue are significant. As a result, it may be worthwhile to retain counsel to ensure that the necessary forms are properly completed and timely submitted to your plan along with the needed documentation. Bear in mind that your plan is likely to employee staff who are expert at protecting the plan’s interests which are unlikely to coincide with your needs.

2. What are some important considerations if I choose to initiate a benefits claim?

 Benefit claim applications can be complex. Some of the important considerations when filing an application are:

(a) Obtain and read your benefits booklet thoroughly to ensure that you follow all claim procedures and submit all necessary claim forms in a timely manner. The benefits booklet is referred to as the Summary Plan Description or “SPD”. The plan administrator, who is most often your employer, is required to provide you a SPD at the time of your enrollment in the plan. If you do not have a current SPD, immediately obtain one from the administrator along with all needed claim forms. If the administrator does not have the required forms, immediately contact the plan’s claim department and request that the forms be sent you. Often, claim forms can be found online if the plan maintains a website.

(b) Contact the plan’s claims department with any questions or concerns that you may have regarding your claim. The contact information can be found in the SPD. Also, your employer’s human resources department should be able to provide you that information. Often a plan representative will contact you regarding your claim via telephone and mail after you file the initial claim application.

(c) It is likely that your plan will record all of your telephone calls with its representatives, and Florida law requires that you be notified of and consent to such recordings. Likewise, be certain that you obtain permission from any representative that you intend to record.

(d) Take advantage of any recorded telephone calls. Be polite, factual and non-emotional as possible but firmly request that the representative answer all of your questions to your satisfaction and in a manner that you can understand. Do not be embarrassed to request that the representative provide clarification or additional information. If necessary, request to speak to a supervisor for additional assistance. Bear in mind that the ERISA statute generally requires plans to communicate with you in a manner that you are likely to understand.

(e) Confirm important information that you discuss with a representative, especially deadlines such as response dates and the requirement for supplemental documentation. For instance, if a representative states that you will have additional time to submit application materials you should send a confirming letter regarding same and further stating that “If this is not your understanding of our conversation, please contact me immediately”. All submissions to the plan should be sent via a traceable means such as facsimile which provides a transmission report or USPS Certified mail with “Return of Receipt Requested”.

(f) Calender the date that the plan is required to respond to your claim application. Plans have vario us response times depending on the type of claim that you are filing. For instance, medical emergency claims generally must be responded to within 72 hours while other types of benefit claims may allow for a response time of several months. Check the benefit booklet known as the SPD that your plan administrator should have provided to you at the time of your enrollment to verify the claims procedures and response requirements. In certain situations, the plan may grant itself an extension of time to respond to your claim and it is generally required to notify you in writing of the extension. The above suggestions are only some of the important considerations when initiating a benefits claim.

We strongly advise you to seek legal representation if you are uncertain of your ERISA rights and duties.

3. Will the plan notify me regarding the status of my claim?

Yes. The claim administrator should provide you written notification whether your benefits have been granted or denied or if there is a delay in the claim decision.

4. What happens if my claim is denied or if previously granted benefits are terminated?

Pursuant to federal ERISA law, the claim administrator must notify you in writing of its decision to deny unpaid benefits. The administrator must cite specific plan language which it relied upon in reaching its adverse decision and in a manner that you are likely to understand. Furthermore, the letter must advise you of your right to file an administrative appeal of the plan’s adverse decision, the procedural requirements for filing such an appeal and your right to bring a lawsuit under the ERISA statute after your administrative remedies are exhausted.

5. Is an administrative appeal usually required if I want to file a lawsuit for unpaid plan benefits?

Yes. Your failure to timely exhaust the plan’s administrative remedies will almost always prevent you from filing a lawsuit for unpaid benefits. The plan’s denial letter should provide you specific instructions on how to file your appeal. If the instructions are not present, you should immediately contact the plan’s claims administrator.

Generally, you will be required to provide the administrator a written explanation of your entitlement to benefits under the plan language, identify any mistakes the plan may have made in reaching its adverse decision, and attach all documents which you believe support your claim. Your failure to timely complete the appeals process can forever prevent you from pursuing unpaid benefits regardless of the merits of your claim.

6. Who has the burden of proof when pursuing an administrative appeal?

The claimant has the burden of timely proving entitlement to plan benefits and ensuring that the plan timely receives all necessary supporting documents. While the plan may request authorization to obtain records from the the various parties involved in the claim such as employers, medical providers, accountants, third-party administrators, etc. it is the claimant’s responsibility to ensure that the plan receives all necessary documentation including completed claim forms. Often, some of the forms must be completed by parties other than the claimant. Bear in mind that it is not uncommon for third parties to ignore such requests, and it is the claimant’s responsibility to ensure that all required materials are timely submitted to the plan.

7. Do you recommend that I obtain legal representation to file an appeal?

Yes. While the ERISA statute does not require legal representation to file an appeal, we strongly recommend that you do so. As previously stated, your failure to meet all of a plan’s procedural requirements during the appeal process can forever prevent you from filing a lawsuit for unpaid benefits. The appeal must be precise and explain any errors the plan made in reaching its benefits decision. This often requires that the claimant provide a detailed analysis and application of plan language and ERISA law to the facts of the claim. It is the responsibility of the claimant, not the plan, to ensure that during the appeal process the plan is placed on notice of its errors in reaching its adverse decision even if the claimant believes the plan should be aware of such errors.

Furthermore, in most all cases the court’s review of a plan’s decision to deny benefits is limited to what the plan knew at the time it rendered its adverse decision on appeal. In other words, the ultimate audience of an appeal is often not the plan but a federal judge. Therefore, it is critical that the appeal be as precise and complete as possible because it is frequently the last opportunity to frame the issues of your claim if a lawsuit is required. We believe that in most instances this cannot be achieved without the assistance of an ERISA attorney.

8. Are you able to represent me if I don’t live in the Cape Coral area?

Yes. Our clients are located throughout the state of Florida, and in most instances our representation is accomplished via telephone, mail, facsimile, e-mail and overnight delivery services. ERISA litigation generally does not require the claimant’s presence in court or at deposition, and in many instances court ordered mediation (where the parties meet to attempt to resolve the case) can be conducted via telephone if necessary.

While we welcome the opportunity to meet our clients in-person, such meetings are often impractical due to travel distances and clients’ physical limitations. Fortunately, this does not impair our ability to zealously represent our clients. We encourage our clients to contact us whenever they have questions or concerns regarding their claims, and we frequently initiate the contact to provide status reports even if nothing has changed since our prior communication. We understand the importance of such contact and the peace of mind that communication can bring especially when so much is often at stake in an ERISA case.

9. Where are ERISA lawsuits filed?

ERISA lawsuits are generally filed in federal court which has jurisdiction over such matters, and cases that are initially filed in state court will almost always be removed to federal court. In certain circumstances, benefit claims that are filed in federal court will be transferred to state court if the federal judge determines that the plan is exempt from the ERISA statute.

10. What standard does the court apply when deciding whether to overturn a plan’s decision to deny my benefits?

The ERISA statute generally provides that a plan must be “unreasonably wrong” for the court to reverse an adverse benefits decision, and in most circumstances the plan receives the benefit of the doubt in making its decisions. That is, the plan’s decision must be both “wrong” and “unreasonable” in order for the court to act. This is an extremely difficult burden for you to meet. Your failure to adequately notify the plan of its unreasonably wrong errors during the appeal process and to supplement your claim with proper supporting documentation can defeat even the best of claims.