When To Hire An ERISA Lawyer?

There isn’t any clear-cut answer as to when you should hire an ERISA lawyer.  Each claim is different, and each person’s situation is unique.   Generally speaking, if you start to feel that you don’t understand the process, or that the insurer does not appear to be dealing with you in good faith, then it is definitely time to speak with a knowledgeable ERISA attorney.

In addition, there are some additional basic guidelines that are centered around the various stages of a disability claim to keep in mind:

The First Stage – Presenting the Claim To The Insurer

The first thing that happens when you become disabled – unable to perform the material duties of your own (or sometimes any) occupation – is that you need to present the claim to the carrier for payment.  The question then becomes – do you hire an attorney at this early stage.  My advice is usually “yes,” hire the attorney.  After all, you “are disabled” and even if you are (or were) quite good at communicating, organizing and presenting, that ability is very often compromised by your disability.  “Yes,” it will cost you some money, but the cost of retaining an experienced ERISA attorney early-on will very often be much less than if you wait until the claim and/or appeal is denied. 

And what should you expect at this early stage? An experienced ERISA lawyer will know how to: (1) complete the cryptic paperwork the carrier throws at you, (2) work with your physicians, and (3) deal with claims adjusters.  The experienced ERISA attorney will also prevent you from making common mistakes that often result in improper claim denial.  For example, disability insurers often provide your physicians with confusing, one-sided, and very limited forms (Attending Physician Statements).  These forms are usually given to the physician without any explanation or guidance.  An experienced ERISA attorney will be able to work with your physicians to avoid common pitfalls and allow your physician to explain, in detail, why you are disabled.  Also, claimants typically do nothing (or very little) to explain the material (important) duties of their occupation, leaving the insurer to fill in those duties themselves. Needless to say, the insurers very often fail to include some very important duties of your occupation.  An experienced ERISA lawyer will make sure that your material and substantial duties are documented at the claim stage.

In general, most claimants should hire an experienced ERISA lawyer even at this early phase.  By doing so, you ensure timely and proper completion of the required documents and information.  This allows you the best chance possible of getting your claim approved at the outset.

The Second Stage – The Appeal of a Denied Claim

If your claim has been denied, it is extremely important that you hire an ERISA lawyer to help with your appeal of the denial.   This is a very critical stage as it is the only time you will have to make sure that everything you need to refer to in Court (if the appeal is denied) is in the insurer’s file (often called “the administrative record”). 

As part of the appeal, you will want to submit as much persuasive evidence of disability as possible, as this will become the only record if you need to take the case to Court.   In many instances, you will not be able to submit additional information (i.e., anything that is not in the administrative record) after the appeal is decided, even if the case goes to Court.   Again, an experienced ERISA lawyer will be able to proactively assist you in making the appeal, whether this includes getting you to the right specialist, submitting the appropriate documentation for the administrative record, and/or communicating with the claims adjusters.

The Third Stage – Going to Court

At this stage, when all else has failed and you have to sue in Court to get your benefits, there is no question that you will want a qualified and competent ERISA lawyer on your side.   ERISA litigation is a complicated process, and an experienced, well-qualified ERISA lawyer will know how to properly handle your case through the litigation process. Do not go to court without a lawyer specialized in ERISA on your team.

At Delfino Green & Green you will find lawyers specialized in ERISA law who are ready to help you at the claims stage and through litigation.