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ERISA LTD Claims, What Happens After Your Appeal Denial?

ERISA LTD Claims, What Happens After Your Appeal Denial?


You have been denied your Log Term Disability (LTD) claim, and have exhausted your administrative appeals. You have gone through every step laid out for you in your ERISA LTD policy and now are now your only recourse is to talk to an LTD lawyer to help you get your denied claim awarded.



For the sake of this article, we are going to be briefly covering appeals to claims governed under ERISA guidelines. ERISA, the Employee Retirement Income Security Act of 1974, is complex federal legislation that was originally designed to protect pensions and retirement plans. It also protects your rights in LTD claims, and in a truly ironic twist, in practice, it often seems to safeguard the interests of LTD insurance companies.


Your Rights to File Suit After Your LTD Administrative Appeal

While ERISA guarantees you an administrative appeals process when first denied, ERISA also results in your options become far more restricted if the claim remains unresolved.

If the administrative appeals process is exhausted, your only option to continue pursuing your long term disability benefits is to file suit in a federal court.

Federal Courts have sole jurisdiction over ERISA LTD claims (lawsuits).  Moreover, the suit will have to be reviewed by a Federal Judge; you will not have the opportunity to present a well-reasoned case to a receptive and impartial jury.


De-novo vs. Arbitrary & Capricious

Once you file your ERISA lawsuit, the merits of your claim are out of your hands.  A Federal Juge must now use either a “De-Novo” or “Arbitrary and Capricious” standard to review your claim. The standard that the judge will use to evaluate your case depends on the details of your LTD policy.

A de-novo (Latin: “of new”) standard is usually the best case scenario and allows for the judge to independently review the merits of your claim. You do not get to influence the judge with new evidence, but you do get to rely on his or her judgment. And that, assuming you have a meritorious claim, very-well might be enough to get your long term disability benefits awarded.

Alternatively, the judge may be held to a standard called “Arbitrary and Capricious.” In common language, this is also known as the “abuse of discretion” standard, and it does not allow for the Judge to make an independent determination on the merits of the claim. The judge, instead, must assess if the insurance company evaluated and subsequently denied your benefits in an incorrect, irrational, or unreasonable way. Unfortunately, this is both the hardest and the most common type of review standard applied in LTD lawsuits.


No New Evidence?!

We have gone into detail about why it is important to make a deliberate effort in getting your administrative appeal setup well. The restrictions of discretion on the part of independent review at the federal court level are why we pushed that point so hard. When you get to the federal court ERISA lawsuit, the facts of the case are already set; you cannot add new information.


If You Win Your ERISA Lawsuit

One of the things we mentioned early in this article was the idea that in some ways ERISA seems to protect the LTD insurance companies better than the beneficiaries of the policies (you). Nowhere is this truer than in the compensation you can expect to receive if it is found that the insurance company was indeed wrong to deny you.

If this is the case, and you overcome a denial of benefits at the federal court level, the best you can expect to recover is the past due benefits you have yet to receive.

There is no recourse for righting the wrong decisions made by private companies that caused you financial and emotional distress. Perhaps if there were a way to hold the insurance companies accountable for poor decision making, they would be more concerned about getting their determination correct the first time.  Instead, they seem to err on the side of denial and make incumbent upon you to prove beyond doubt that you rate the disability benefit they are (without risk) denying.


Your Best Bet in ERISA LTD Appeals

Your best approach when facing an ERISA LTD claim appeal is to get the strongest possible case put forward in your administrative appeal. An experienced ERISA LTD attorney will help you out with this. Moreover, working with an ERISA LTD law firm like Roy Law means working with someone who knows the complexities involved at all levels of the LTD application and appeal process.

Save yourself a world of stress, and set yourself up for success. Contact us.


About the Author
In 1998, Chris obtained his law degree from the University of Oregon, and in 1999, he accepted his first job as an attorney with the Washington State Attorney General’s Office. In 2000, Chris entered a private litigation practice in Vancouver, Washington. In private practice, Chris litigated a variety matters including administrative, criminal, real estate, construction, business, and insurance.