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Erisa Claim Denial Appeals

ERISA Life, Disability, Long Term Care and Health Insurance Appeals:
What Do I Do Now that My Claim has been Denied?

Most of our clients first come to us shortly after they receive a telephone call or letter informing them that their disability claim, long term care claim, health insurance pre-authorization request, or claim for life insurance benefits has been denied or terminated.  For example:

  • You may be in the hospital and your treating physician recommends a particular medical procedure or a longer stay, but your insurer refuses to approve or pre-authorize coverage; or
  • You may have been on disability for several years, but suddenly your insurer tells you that you are well enough to return to work; or
  • You may have been approved for and receiving covered home health care services, but suddenly the insurance company says you’re able to do more activities of daily living without assistance; or
  • Your insurer has denied your claim for short or long term disability benefits in the first place.

We can assist you in preparing the appeal to reverse such benefit denials and terminations. Since most people receive their health, life, long term care, and disability insurance coverage through their employer, many of these claim denials will be governed by a federal law called the Employee Retirement Income Security Act (ERISA), which governs coverage and benefits under most employer-sponsored pension and benefit plans.  ERISA provides a wide variety of procedural requirements and protections, including a mandatory internal appeal procedure.  We can assist you in enforcing your rights, which may include access to plan booklets and insurance contracts, as well as reports, emails, telephone logs and other documentation reflecting your insurance company’s handling and determination of your claim.  We can review your plan booklet and claim file and advise you on how best to prepare an effective appeal.

We can also advise you with regard to other rights you may have under New York law and other federal laws.  New York, for example, provides an “external review” procedure for certain kinds of health care claim denials — typically, those where the insurance company claims that your treatment or drug is not medically necessary or is experimental or investigational in nature.  External review appeals, which are subject to strict deadlines, may be available in addition to, or in place of, ERISA internal appeal procedures. Because external reviews are generally conducted through the New York State Insurance Department, you may feel that such review is more likely to provide a fair and independent determination of your claim for health insurance benefits.

We try to provide flexible levels of service to accommodate the different functional and financial needs of our clients.  If a client feels able to write an appeal, we can participate in an advisory capacity — providing initial suggestions and then commenting on draft versions of the appeal.  If a client is able and willing to do leg-work, such as obtaining medical records, this can reduce attorney time dramatically.  Similarly, client questions presented by letter, fax and e-mail, can sometimes be more efficient and cost-effective than doing so by telephone.  Finally, in certain appropriate cases, a contingency fee arrangement may be mutually satisfactory (rather than a straight hourly billing arrangement).  Such an arrangement may not reduce the amount of fees ultimately paid, but may postpone the fees until an award or settlement is achieved.

TELEPHONE:  212-406-9606

Mark Scherzer Law :: Long Term Care Claims :: Long Term Disability Appeal Lawyers :: Health Insurance Coverage Appeals
New York Attorneys (including Sullivan County, Ulster County, Dutchess County, Delaware County, Greene County, Columbia County, Albany County and Rennselaer County)

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  • New York Office
    110 Lasher Avenue
    Germantown, New York 12526
    Phone: 212-406-9606
    Fax: 212-964-6903
Office Hours
Monday – Friday | 9:30 a.m. – 6:00 p.m.