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Denied ERISA Life Insurance Claims

You may be surprised that one of the first things that must be done in handling a denied life insurance claim is to determine whether state law or ERISA law applies. The answer to that question will determine how a wrongful denial is appealed, whether a law suit has to be filed in state or federal court, what is the legal standard is to overturn a wrongful denial and whether there is a jury trial.

What Is ERISA and Why Is It Important in a Life Insurance Claim?

A history lesson will help you understand the importance of the answer as to what law applies to a denied life insurance claim. 

In the 1970’s, Teamster Union President Jimmy Hoffa stole his union’s pension fund money and Congress decided to do something to protect benefits of working Americans. It enacted the Employee Retirement Security Act of 1974.

ERISA, as the law is known, governs welfare benefit plans such as life insurance, accidental death and dismemberment (AD&D), disability insurance, group health insurance and pensions, which are offered by non-government or church based employers.

One of the first questions that must be asked if your claim is denied, is whether the insurance policy or plan is covered by ERISA or whether the insurance policy was a privately purchased individual insurance policy.

The answer is crucial!

If, for example, you work for the City of St. Petersburg or the Diocese of St. Petersburg, any claim is governed by state law. It is state law breach of contract claim which allows for depositions and other discovery, a trial by jury and claims for bad faith, compensatory damages and punitive damages.

On the other hand, if you work for a company life AT&T, Jabil Circuits, Raymond James Financial, any claim for delayed or denied life insurance, AD&D benefits or disability benefits is governed by ERISA.

ERISA regulates the conduct of insurance companies and has strict regulations for the filing of a disability, life and AD&D claim, how and when an appeal of a delayed or denied claim must be filed, and the filing of a lawsuit.  Generally, federal and not state law will govern a case.

Federal court is NOT a friendly place for a beneficiary whose claim has been delayed of denied.

Worse yet, despite Congress’s effort to protect working Americans, it let insurance companies like Hartford, etc put a golden handcuff in disability, life and AD&D policies. We call it the “get out of jail free card.”

This “get of jail free card” is called a discretionary clause. It gives the insurance carrier the right to interpret the terms of the policy or plan in their favor and the right to decide if a claim is paid. A discretionary clause says that a federal judge can only overturn a claims denial, if the claim denial is “arbitrary and capricious.”       

The answer counts and makes all the difference in the world in getting the life insurance benefits.

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What are the Three Primary Reasons for An ERISA Life Insurance Denial?

There are three primary reasons for a life insurance claims denial.

First, the life insurance carrier will argue there is no coverage by saying:

  • The policy holder was not eligible for coverage,
  • The policy holder did not timely elect coverage,
  • The policy holder made a misrepresentation on the application,
  • The policy holder did not complete the application,
  • The policy holder didn’t pay the premium so coverage lapsed,
  • The policy holder didn’t change you to be the beneficiary after the divorce,
  • The policy holder’s employer did not forward the application to the life insurance company.

Do any of these reasons sound familiar?

Secondly, the life insurance carrier will justify a denial based on their self-interested interpretation of the life insurance policies. Many times, life insurance carriers will interpret the terms of the policy in their favor and deny a claim on the basis that the death was caused by an act or event that was excluded under the terms of the policy:

  • The policy holder’s death was suicide,
  • The policy holder’s was caused by the use of alcohol or drugs and a reasonable person would expect that death would result in death,
  • The policy holder died in a foreign country,
  • The policy holder’s death is excluded under the sickness exclusion.

Lastly, the life insurance company will use “liar for hire” pathologists, toxicologists and other physicians to create “medical” reasons to justify a claims denial. For example, a claim might be denied on the medical basis that:

  • The policy holder’s death was not an accident,
  • The medical examiner listed the cause of death as a heart attack, stroke, embolism, or some other medical condition that resulted in death,
  • The cause of death is excluded under the terms of the policy.

You need an attorney who understands how and why life insurance carriers deny  claims, can attack the reasons for the claims denial, develop the factual, legal and medical evidence needed to win a claim, write a shock and awe appeal and delivered it to the life insurance company in a box that hits their desk with a resounding thud.     

Call today at 727-   –      for a complimentary 30 minute consultation.  No recovery, no fee guarantee.     

Is the ERISA Life Insurance Carrier Denying the Payment of a Life Insurance Claim?

Once it is established the denied life insurance claim is governed by ERISA, there are some very important things you must know about ERISA and a denied claim.

  • Under the regulations, a carrier must give you, if you ask, a copy of your entire claim file.
  • Under the regulations, you only have 180 days in which to file an appeal of a denied claim.
  • Under the regulations and case law, if you don’t timely file an appeal or don’t file an appeal at all, you lose, regardless of whether the denial is wrong.

What You Should Do Now If Your ERISA Life Insurance Claim Has Been Delayed or Denied!

You owe it to yourself and other beneficiaries to contact an experienced nationwide ERISA life insurance lawyer today!

Remember, you only have 180 days in which to file a written appeal of a denied life insurance claim.

The appeal is the trial of the life insurance claim. Simply saying you are appealing won’t cut it. It is crucial that you immediately hire an experienced ERISA life insurance attorney who understands, not only the reasons the claim was denied, ERISA law and regulations, and who also knows what it takes to write a winning appeal.

This is a complex area of the law that also involves medical causation and proof issues. While some lawyers may suggest they understand ERISA, the reality is that they don’t and most don’t understand the medical basis for the denial.  Don’t take a risk by hiring a lawyer who knows nothing about ERISA law or is afraid to be in federal court.   

At our firm we analyze both the legal and medical basis for the denial. Our appeal letter provides the carrier with a comprehensive summary of the policy language and applicable case law not only across the nation but the law applicable to this case. We explain why the life insurance carrier was legally wrong in its claims denial.

Next, we analyze the medical reasons for the denial and, if necessary hire accident reconstruction experts, toxicologist and the necessary medical experts to challenge the bogus, made up and inaccurate medical conclusions reached by the carrier’s “liar for hire” experts.

The appeal is the last time to present evidence in the case because rarely is new evidence allowed if a lawsuit has been filed. 

Filing a Timely ERISA Life Insurance Lawsuit

Life insurance companies are not in the business of paying benefits and, sometimes, you have to sue them in federal court.

But not filing on time, can destroy even the best life insurance case. Why? There is no statute of limitations in the ERISA law. The policy or plan will set the time in which a lawsuit must be filed and, generally, courts will uphold the policy or plan statute of limitations.

Remember that you have to timely exhaust the appeals process and timely file a lawsuit. These are just two reasons you should our name represent you. After all, we are experienced ERISA life insurance lawyers who help life insurance beneficiaries across America get the life insurance benefits they are owed.

Our goal is to key your benefits quickly and protect your rights as beneficiary of the policy. If there is no recovery, there is no fee. We have successfully recovered money for our clients, despite life insurance company’s practice of delaying or denying benefits. 

Don’t trust your claim to a personal injury, family law attorney or Social Security disability attorney. We handle ERISA claims nationally and take on insurance carriers like AIG, American Fidelity, Assurity, Guardian, Mass Mutual, Mutual of Omaha, Unum, Liberty Life, NAME 1-N

You can learn about denied ERISA AD&D claims next.

No Legal Fees Unless We Win Your Case!

Our fee is pretty simple.  The legal team at Life & Accident Claim Lawyers work on a contingency fee basis which means they don’t get paid unless they collect the life insurance benefits that are delayed or denied as a result of a settlement or trial.

Once we collect those benefits, we charge a fee that we all agree on when we are hired to represent you, the beneficiary, or the estate of the policyholder. The fee is flexible and is based on whether the claim is delayed or denied and how medically or legally complex the case might be.

We guarantee you will be comfortably with the fee!

Don’t let the life insurance company rob you and your family of its peace of mind and financial security. Your loved one didn’t pay years of premium so the life insurance carrier could profit from a wrongful claims denial.

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