Handling ERISA Accidental Death Coverage Denials
The Employee Retirement Income Security Act of 1974 (ERISA) regulates insurance plans offered by private employers. Through ERISA, employees are guaranteed certain rights in insurance coverage. Unfortunately, insurance companies frequently deny claims despite ERISA’s protections.
When insurance companies deny a valid wrongful death claim in violation of the law, you may still recover denied benefits by appealing. However, appealing accidental death coverage denials through complex ERISA provisions is difficult to navigate without help.
Thankfully, the Peace Law Firm has represented clients in ERISA claims and appeals for over 20 years. We have the experience, training, and knowledge to guide you through filing and appealing an accidental death claim. ERISA claims operate on a short timeline, so reach out as soon as possible to learn more about our services.
What Is ERISA?
ERISA is a federal law that regulates insurance plans offered by private employers. It does not generally cover government employees, church employees, or plans provided solely to comply with other laws.
Under ERISA, employers must provide specific details about insurance coverage in a clear and easy-to-understand format, including when accidental death is covered and who may file an accidental death claim. You may recover damages to compensate for your losses related to a wrongly denied ERISA claim.
What Is an Accidental Death Claim?
Under ERISA, employers must provide details about what your insurance covers in an accidental death claim. The policy may identify certain people who can file an accidental death claim, like a parent, child, or spouse.
When you file a claim, the company determines whether it fits into the “accidental” death category, as defined by its policy. Generally, an accidental death is:
- Unintended,
- Unexpected, and
- Unforeseen.
An insurance company may deny an accidental death claim if it determines the death was not “accidental.” This may occur when the insurance company decides that the victim or someone else caused the death in some way.
Common reasons for denial include intoxication, pre-existing medical conditions, or that the victim or someone else intended the death to occur.
What Can You Do If Insurance Denies Coverage on Your Accidental Death Claim?
If you receive a denial of an ERISA-covered accidental death claim, contact an ERISA claim attorney as soon as possible. You are entitled to appeal, but the process is time-sensitive and confusing.
To appeal, you request an internal review of your claim with the insurance company. You can appeal to a federal court if the company denies your claim again.
Internal Appeal
Before you can sue based on a denied benefit covered by ERISA, you must request an internal review through procedures outlined in your insurance plan. During that review, someone who has yet to review your claim reviews it to determine whether the initial denial was correct.
You are entitled to a full and fair review of your claim, but different companies may follow different procedures. Regardless of the specifics, you can and should provide as much evidence supporting your claim as possible at the internal review stage.
You want to create a strong body of evidence at this stage because you will not get another chance. When you appeal to a court, it generally uses the body of evidence you create during the internal review stage to decide. In other words, you usually cannot introduce new evidence in court.
Insurance companies may purposefully obscure that ERISA works this way in their policies. You may also feel that there is little reason to present your best evidence to an insurance company that has already denied your claim.
Even though you might not expect the insurance company to treat you fairly, it helps to prepare your internal review claim like you would a case before an impartial judge.
Court Appeal
If the company denies your internal appeal, you have the right to appeal to a federal court. Taking your claim to federal court does not entitle you to a jury trial. The federal court generally makes a decision based on the record you create during the internal review—the administrative record.
Along with the administrative record, your lawyer submits a written argument to the court about the facts and the law in the case. The process looks more like appealing a trial court's decision to a higher court, making it essential to have an experienced attorney’s assistance when you file your initial internal appeal and create the administrative record you will rely on in court.
Get Help Filing an ERISA Claim
At the Peace Law Firm, we focus our efforts on ERISA claims. We understand the ins and outs of the law and can guide you through filing a claim, creating an effective administrative record, and appealing to federal court. Insurance companies have experienced lawyers providing advice and counsel, and so should you. Contact us today to speak about your options.
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