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ERISA Claimants Must Exhaust Their Administrative Remedies

Fri Oct 19th, 2018 on     Insurance Claims,    

If you have had your insurance benefits claim denied or otherwise mishandled by your insurance company, then you’re entitled to challenge the adverse determination made by your insurer under Florida (and federal) law.  It’s important to note, however, that the procedures and limitations applicable to your case will be somewhat different than the “standard” if your insurance benefits policy is ERISA-governed.

The Employment Retirement Income Security Act (ERISA) is a federal regulatory scheme that establishes a unique set of standards, protections, and limitations that are applicable to qualified plans (e.g. all private insurance benefits plans that are provided or sponsored by one’s employer, so long as it is a non-religious organization).

Among the unique requirements imposed by ERISA is that of “administrative remedy exhaustion.”  Those looking to claim benefits under an ERISA-governed plan are likely to encounter this limitation.

Let’s take a look at some of the basics.

ERISA Remedy Exhaustion Basics

If your claim has been denied — or if you have been subject to some other serious and adverse determination (i.e., undervalued claim, award of partial benefits as opposed to full benefits, etc.) — then you may challenge the insurer’s decision, but ERISA requires that you go through an internal process known as the “administrative appeals” process.

More specifically, ERISA requires that claimants first exhaust their administrative remedies available under their plan — the internal appeals process — before bringing a lawsuit in civil court.  In fact, claimants are not legally entitled to bring a lawsuit until they have exhausted their administrative remedies.  Some ERISA plans require that claimants go through several rounds of administrative appeals before they have fully “exhausted” their remedies, so bear that in mind.

The administrative appeals process is more complex than many claimants may realize and involves its own unique collection of formal deadlines and procedures.  We therefore encourage you to consult a qualified attorney with experience handling ERISA administrative appeals to guide you through this process.

Though the administrative appeals process is an internal one and is therefore fraught with difficulties relating to fair and unbiased resolutions, there may still be an opportunity to resolve your dispute favorably (and avoid litigation).  If you can put forth a clear argument as to why the insurer’s adverse determination was incorrect (and possibly unjustified in the first instance), then the insurer may simply reverse their determination to avoid further litigation.

Request an Appointment With an Experienced Miami Insurance Litigation Lawyer

Ver Ploeg & Lumpkin, P.A. is a Miami-based insurance litigation firm whose attorneys boast decades of experience representing policyholders in a range of insurance disputes, including those that involve ERISA-governed benefits plans.  We have extensively litigated claims relating to the denial of benefits under ERISA and understand the unique challenges and procedures typical of such disputes.

Unlike many of our competitors, we believe that the most effective legal representation is that which engages the client as an equal partner.  We are committed advocates with a focus on client-oriented advocacy — as we communicate regularly and openly with our clients, we are better-equipped to develop a thorough understanding of the benefits plan and the overall case at-issue.  This approach to litigation has led to a number of successful case results.

If you’d like to speak to an experienced Miami insurance litigation lawyer at Ver Ploeg & Lumpkin, P.A. about your potential ERISA-related benefits claims, call (305) 577-3996 to get connected today.

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