ERISA Claims and Exhausting Administrative Remedies: What You Need to Know
Before you file an ERISA lawsuit, you must follow a very specific process, and a single mistake can have serious consequences. Unfortunately, many disabled people don’t fully understand how ERISA claims work.
In this article, our experienced disability insurance lawyers outline the basics of an ERISA claim, how to “exhaust your administrative remedies,” and when you can file a disability insurance lawsuit.
What Is the ERISA Claims Process?
ERISA (Employee Retirement Income Security Act of 1974) applies to most employer-funded benefit plans, including long-term and short-term disability policies. Many claimants mistakenly believe that this administrative appeals process will be quick and informal.
Unfortunately, the ERISA administrative appeals process has its own set of deadlines and procedures. Depending on the language of your ERISA plan, you may be required to go through up to two rounds of administrative appeals before you have fully “exhausted” your administrative remedies.
The typical process involves the following steps:
- Application for benefits: You submit forms and information that notify the insurance company about your disability insurance claim.
- Claim investigation: A claims adjuster reviews your information, medical records, job-related documents, and other evidence. Based on their assessment, they will either approve or deny your claim.
- Administrative appeal: If you’re denied, you must file an appeal with the insurance company. You can (and should) add missing evidence and provide legal arguments about what you’re eligible for disability insurance. This may be a multi-stage process.
- Insurance company’s final decision: The insurance company will review your claim and issue another decision. This is their final decision, and it ends the administrative appeal process.
- Federal lawsuit: Now that you’ve “exhausted your administrative remedies,” you can file a federal lawsuit.
You cannot skip any of these steps; if you file a lawsuit before exhausting your administrative remedies, the court will reject your claim.
The administrative appeal process is essential to your ERISA claim. During this period, you can submit additional evidence for the insurance company to consider. This may include medical records, functional capacity evaluations, detailed letters from your physicians, and experts’ reports.
Typically, your disability insurance lawyer will request a copy of your administrative file (the insurance company’s file about your claim) and supplement it with as much supporting evidence as possible.
- Related Article: How Long Do I Have to Wait for a Disability Insurance Decision?
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What Happens Once I Exhaust My ERISA Administrative Remedies?
Once the insurance company issues its final decision, you have officially exhausted your administrative remedies. That means you can file a lawsuit in a federal district court. However, you must follow specific legal procedures and requirements.
First, you must file your lawsuit within a specific time frame. ERISA does not have its own statute of limitations, which is the part of the law that sets the deadlines for filing a lawsuit. Instead, the courts will apply your state’s most similar filing deadline. In Illinois, you have 10 years to file an ERISA lawsuit.
Filing a Complaint and Serving Your Lawsuit
When you file a lawsuit, you’ll have to file a series of documents, including a complaint. You must pay a filing fee, and you also need to serve the documents to the insurance company. If you have an ERISA lawyer, they will take care of all of these details for you. If you are unrepresented, you still must navigate all of these issues, and the Clerk of the Court cannot give you legal advice.
No Jury Trials
The courts do not currently permit jury trials in ERISA lawsuits, even though many lawyers argue that claimants should have a constitutional right to a trial under the Seventh Amendment. Instead, a federal judge will review your arguments, examine the evidence, and issue a decision.
What the Judge Will Consider—and What They Won’t
Federal judges are limited in what they can evaluate in an ERISA lawsuit. Once the insurance company makes its final decision and you exhaust your administrative remedies, you no longer can submit additional evidence. There are some limited exceptions to this rule; if you have questions about submitting additional evidence, consult an experienced disability lawyer.
However, federal judges in Illinois do have broad discretion when they review your ERISA claim and administrative record. Judges use a “de novo” standard of review, which means that they can consider all of the evidence and do not have to defer to the insurance company.
- Related Article: Why Does Federal Law Apply to My Disability Insurance Claim?
Does ERISA Apply to Every Disability Insurance Claim?
No. If you purchased your own disability insurance, state laws apply to your claim. ERISA covers most employer-sponsored disability insurance plans, but there are exceptions to this rule. For example, ERISA does not cover “church plans” and government employees’ benefit plans.
If you’re unsure whether state or federal laws control your legal claims, contact our office today. Our experienced ERISA lawyers can evaluate your plan and educate you about your legal options.
Bryant Legal Group:
Chicago’s Respected Disability Insurance Lawyers
At Bryant Legal Group, we’ve helped people throughout Illinois get the disability insurance benefits they deserve, recovering millions in compensation for our clients. If you’d like to learn more about our sophisticated, client-centered approach to ERISA and disability insurance appeals, contact our office today.
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