ERISA appeals are incredibly important. There is a series of case law that holds that you must appeal the denial of your claim for benefits before you proceed to court. If you don’t go through that appeal process with certain very limited exceptions, your case will likely be dismissed. So for that reason alone, the appeal is incredibly important. But there’s another, more significant strategic reason why your appeal is important.
First of all, if you do a thorough, well-written appeal, you have a better chance of being successful on appeal. If, however, the appeal is unsuccessful, you have to assume, once you go into court, that that may be the only thing the judge looks at in the case. Many of us think of litigation, and civil litigation in particular, like we see on television. Most people don’t have much interaction with the court system. And so when we envision a civil lawsuit, what many of us think of is people coming to court, a jury sitting in a jury box, witnesses coming in, testifying in court, providing evidence, the attorney standing up, giving a presentation, and then the case is decided.
A risk of benefit claims are typically not handled that way. So as an initial matter, you don’t get a jury. Secondly, the judge will typically only look at the record that is created on appeal. So you have to assume, as the attorney, once you get into court, that your ability to obtain discovery may be limited and that you should approach the appeal with the mindset that you will never have an opportunity to provide additional evidence. We’re going to try in every case to obtain discovery and make the record more robust because we can only add so much to it during the appeal process, but we approach each appeal as if that is the case. So that’s the opportunity to make sure we have all of the relevant plan documents complete copy of the insurer’s file, all of the relevant records. Typically, if we’re talking about a disability or a life insurance claim, that would be medical records. If we’re talking about a retirement plan claim, we’re talking about work history records, payroll records, social security earnings, what have you. But we want to make sure that we have that entire body of evidence, everything we can possibly get our hands on during the appeal process, and submitted to the fiduciary who’s deciding the appeal.
The other thing we want to do is make sure if there is any other evidence or documentation that we think would be helpful. For example, if we’re talking about a disability claim, perhaps there’s medical literature that would be helpful in explaining your client’s condition, and that’s particularly so if your client has a somewhat rare medical condition; all of that information you want to submit with the appeal. If your client’s been approved for social security disability, while that’s not controlling on your risk of disability claim, it’s helpful. And so you perhaps want to get the complete Social Security disability file. That takes time, but you want to submit and create a really robust record during the appeal so that if the appeal is unsuccessful and you go to court you have everything you think you need there in that record before the court and that you can cite to it as you are briefing your motion for summary judgment and trying to explain to the judge why you should win the case and why the Decision that you’re suing over was incorrect. If you don’t do that, you could find yourself without critical pieces of information or evidence that could help you win on your case on appeal.
That’s why we like to have clients come to us at the beginning, when their claim has, in a perfect world, before they’ve even submitted a claim, but when their claim has been denied, not after they’ve submitted an appeal. In many cases, we’re unable to assist people when they’ve handled the appeal on their own because the record is not sufficiently well-developed for us to do what we need to do in court. So it’s really important, whether you work with a Garner Firm or another law firm, that you hire an experienced ERISA attorney who knows what they’re doing, who can build a robust and fully developed record in connection with your appeal so that you are in the best possible position to litigate that case, if necessary, in court.