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How to Prepare for Your ERISA Appeal

Close up of successful doctor reading documents and preparing for her ERISA appeal

1.     Once you have received your denial or termination of benefits letter from your carrier you should not speak at length with your claims representative or argue with them, immediately ask for your “claims file” and your full policy if you do not already have it on hand. Ask that your appeal deadline start once you receive your claims file.  Traditionally carriers give you 180 days to appeal,  but as always with any insurance company.

2.     Review your denial of benefits letter very carefully then refute each and every false statement made by the claims representative in writing.   Keep your response factual and be certain you have the evidence to back up your statements. Medical records, letters from doctors, work supervisors, or colleagues are helpful. Never exaggerate. 

3.    Open a file and keep copies of all correspondence and conversations. 

4.    Schedule up-coming doctor’s appointments to confirm your condition and document your diagnosis and prognosis. If the appointment can not be made until outside the appeal deadline request an extension and confirm it in writing. 

5.     Make sure you continue and keep a record of your treatment and any supplementary care prescribed. 

6.     If an IME, “insurance medical exam” is scheduled there are a few things you want to do to prepare for the exam. Attempt to bring a friend or family member as a witness. Take notes of the actions of the doctor or what transpired during or after the examination. 

Was the doctor distracted or interrupted by calls or staff? Did he call you by the wrong name, or refer to the wrong file? Take note of how long it took you to get to the exam, what accommodations you had to make in your travels, for instance, if you have a bad back, lying down on the back seat, how long you were made to wait before being seen.  

7. Follow up your phone conversations with your claims representative by memorializing the conversation in writing with an email, fax, or letter.  

8. If you leave the claims representative a voice message, follow up with an email, fax or registered letter stating you had just now left them a voice message regarding xyz and you will look forward to hearing back from them.  

9. Please know that the only evidence that can be used in a lawsuit with the ERISA court of appeals is your written appeal.  It is a judge that determines the outcome of your case. You will not be allowed expert witnesses, new evidence, or a jury of your peers. This is why your appeal needs to be detailed and very thorough.  Your appeal is your only evidence.

10. Most lawyers will not file a lawsuit in which he or she did not compile the evidence.

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