ERISA Claims & 5 Mistakes Made When Filing - Mistake #4
Over the next few weeks, we'll be discussing five mistakes individuals make when filing ERISA claims for long term disability and short term disability, life insurance, pension or retirement, and sometimes large medical benefit claims.
The fourth mistake is failing to refute the evidence that the insurer or the plan administrator is relying on to deny a claim.
This is a common mistake that inexperienced ERISA practitioners or lawyers who don't usually handle ERISA cases often make. This failure involves the basic concept that when you're presenting a case, you make your pile of evidence higher than the other side's pile of evidence. And that should be enough to win the case. However, that's not how ERISA works.
Many plan documents reserve discretion to the insurer or the plan administrator. That means that if they
have a wrong but reasonable basis for denying a claim, they still win, even if your pile of evidence is higher. Therefore, it is a critical mistake to fail to refute the insurer or plan administrator's evidence.
To do this, you have to review each piece of evidence in the claim record they are relying on to deny the claim. Then, assemble evidence that refutes that evidence. The insurer may still deny your claim and disregard your evidence; however, it will then be up to a court to decide whether it is an unreasonable decision. If you presented substantial evidence showing that the insurer or plan administrator's evidence is unreasonable, then you are in a much better position to win the case.