When it comes to filing an ERISA disability claim, you will face different litigation issues than you would with an individual long-term disability plan. The Employee Retirement Income Security Act is a federal act of legislation, which means that all disability insurance claims and disputes are dealt with in Federal Court. If you are filing an ERISA claim, it is important to know that these cases are generally difficult to win as most judges side with the insurance company.
ERISA Disability Claim Complications
The main reason that ERISA claims are more difficult to win than other disability claims is because they are only brought before a judge, not a jury. The amount of information that can be presented in an ERISA case is also limited to that which was gathered during the initial appeals process by the claims reviewer. Evidence outside of the administrative record is not admissible in federal court, which means that you have less to base your claim upon. However, it is possible to use the administrative record to your advantage if your claim has been denied unfairly or handled carelessly.
ERISA Federal Court Standards
The standards used to review an ERISA case are the “arbitrary and capricious” or “abuse of discretion” standard and the de novo standard. These two standards work very differently when determining the outcome of a claim. The first is highly restrictive and always favors the insurance company by requiring that you prove your claims reviewer acted arbitrarily or capriciously during the denial process. The de novo standard simply dismisses the claim reviewer’s decision and allows the court to make a new decision. Most cases are determined by the de novo standard by default unless the plan administer is allowed to interpret the policy.
Exceptions to the Arbitrary and Capricious Standard
There are cases when a plan administrator becomes involved that may not default to the arbitrary and capricious standard. ERISA legislation requires the benefit plan administrator to act in your benefit. However, if the plan administrator is also an insurance company claims reviewer, a conflict of interest has arisen because a claims reviewer is always required to act in the best interest of the insurance company. If you can prove that this conflict of interest exists, your claim’s arbitrary and capricious standard may be converted to the de novo standard. Each of these exceptions is subject to evaluation on an individual basis by the court.
Examples of Conflict
Conflicts of interest can often be a gray area, so it is important to recognize the various ways in which they present themselves. From inconsistent reasons for denial and changes made without additional evidence to making deductions about material facts without the proper supporting evidence, there are many ways you can prove that a claims reviewer is acting unfairly. Claims reviewers may also demonstrate a conflict of interest by failing to provide you with sufficient notice that your claim has been denied or by relying on an inappropriate standard of what constitutes a disability. Your claim may also be converted to the de novo standard if you can prove that the administrative record shows a consistent pattern of adversarial behavior towards you due to his or her role as an insurance company plan administrator.
Contact an ERISA Disability Claim Lawyer
ERISA claims are difficult to navigate, especially if the insurance company has stacked the decks against you with an arbitrary and capricious standard and a claims reviewer who also works for the insurance company. There are steps you can take to minimize the role that such a conflict of interest plays in your case and receive the fair consideration you deserve in Federal Court. Contact the attorneys at Hiller, PC today at (212) 319-4000 for more information on being prepared for your ERISA disability claim.
