Employee Benefit Claims (ERISA)
We represent individuals who have employee benefit claims for life insurance benefits, pension benefits, health and medical benefits, severance benefits, and long term disability benefits. ERISA is the federal law which applies to almost all employee benefit claims.
ERISA stands for Employee Retirement Income Security Act. Most folks think about pensions or even 401k plans when they hear the term ERISA. However, it covers a great deal more than that. It affects nearly all employee benefits in private employment.
ERISA changes the way disability claims are handled legally. Such changes include:
- a requirement that the claimant exhaust administrative remedies, with specific time limits for "appealing" the initial denial of his claim;
- an administrative record which is controlled by the insurance company or other claims fiduciary;
- a requirement that the evidence be in the administrative record before the court will even consider it; and
- a standard of "arbitrary and capricious" review. Where the "arbitrary and capricious" standard applies, the courts often refuse to reverse the claims administrator (often an insurance company) unless the denial decision is completely unsupported in the record. One federal appeals judge went so far as to say that the decision must evoke a "loud guffaw" before it could be reversed by the court. While the legal standard is not quite that bad, it is something to be concerned about if you wish to pursue an employee benefits case.
As you can tell from some of the information outlined above, ERISA is an area of the law which favors the employers and the insurance companies. Defendants spare no cost when it comes time to defend their benefits decisions. It is therefore imperative that individual claimants seek and obtain experienced, knowledgeable counsel.