380 South Melrose Drive, Suite 333, Vista, California 92081
16870 West Bernardo Drive, Suite 400, San Diego, California 92127
Telephone: (760) 565-2027 or (858) 333-7133 - Email: hbhellen@gmail.com


Anatomy of an ERISA Case - Steps in Obtaining Benefits

ERISA disability and health benefit cases are intensely complicated. Before any lawsuit can be filed in federal court, the claimant must submit an internal written appeal contesting the claim denial. Because the internal appeal must be extremely comprehensive, we advise that a seasoned ERISA claimant's attorney prepare the appeal. Unlike nearly all other cases, most evidence cannot be introduced in court only after a lawsuit is filed. Oppressive requirements under ERISA mandate that only the "administrative record" can be examined by the Court, and no post-filing doctors and vocational experts can testify.

Of course, the initial "step" is to file a disability or medical benefit claim. If the claim is allowed, you are done and should start receiving your benefits.

In the event your claim is denied (an all-too-frequent occurrence) you must begin the internal appeal, preferably with counsel. The appeal must be thorough and complete. A good appeal can make the difference between a good settlement and a poor one, or even winning or losing a case in federal court.

ERISA gives you a certain amount of time to complete the appeal of a claim denial (generally between 90 and 180 days) and then the insurer or other plan administrator has generally 45 days to respond, with a one-time extension of another 45 days. Some internal appeals work, but even if they don't, you have to do them in great detail in order to have a chance of winning in Court if your appeal is denied.

If the denial is affirmed after the internal appeal, then a lawsuit is the last resort. An ERISA lawsuit for recovery of disability or health benefits is one of the hardest and most complex areas of law. The law has changed constantly and can affect each and every case an ERISA attorney is working on. For example, the Supreme Court has made several decisions in the last couple of years that have constantly changed the "game plan" for the plaintiff.

These cases do not allow a jury, so it is up to a federal judge to decide whether the disability or medical benefits should be granted. Fortunately, here in California we are within the Ninth Circuit, which is the most pro-claimant Circuit in the country. This firm has succeeded, either by way of settlement during the litigation or favorable judgments, in approximately 80% of all matters handled.

Should a case be lost at the United States District Court level, an appeal can be filed with the United States Court of Appeal for the Ninth Circuit (or whatever Circuit is appropriate). This process also calls for an even more scholarly, detailed approach engaged in by possibly no more 50-60% of plaintiff's ERISA attorneys.

This firm has engaged in a number of Ninth Circuit Court appeals, most of which have been published in the Official Reporters.