At times, Texas employees may file a claim with their insurer only to see it denied. If your insurance plan is covered by the Employee Retirement Income Security Act of 1974 (ERISA), this law provides for you to sue your insurance company in court to try and claim benefits you believe are unjustly being withheld from you. According to Findlaw, however, a plaintiff may miss out on convincing a judge of his or her claim if the judge does not receive the proper documentation.
During a ERISA lawsuit, a judge will consult the file the insurance company possesses on the policy holder to make a decision. This file is composed of all the documents that relate to the policy holder’s insurance plan, as well as insurance claims the policy holder has made, along with denials and subsequent appeals. This file can literally make or break a ERISA case, so any plaintiff wants as much information as possible in the file to support the plaintiff’s argument.
While this file is maintained by the policy holder’s insurance company, an employee can try to fill the file with enough information that will support his or her case. ERISA first requires that employees appeal to their insurer if they are turned down for compensation. During this appeal process, an employee can provide the insurer supporting information that will go in the file. These documents can include reports from physicians and letters drafted by employers.
In the event the insurance company turns down the appeal, this information will remain in the file. With these documents in the employee’s file, the judge will be privy to information that supports the claim of the plaintiff. Without it, a judge will only be exposed to the insurance company’s explanation for why the employee’s claim was denied, and may defer to the insurer’s reasoning over the plaintiff’s claim.
This article is intended to educate readers on ERISA claims and should not be taken as legal advice.
