A well-written, thoroughly supported appeal letter can improve your chances of winning your ERISA appeal. Further, if your appeal is unsuccessful and you pursue litigation, the letter can be fundamental to presenting your evidence in the best possible light when it is reviewed by a federal judge.
One of the great advantages of hiring an experienced ERISA attorney such as J. Price McNamara is that he has written numerous ERISA appeal letters and knows the precise language to use and theexact organization to follow. He can ensure that your appeal letter is based in fact and provides a compelling summary of your stance, the evidence you have of your injury and your inability to work, and why the original denial by your plan administrator should be overturned.
Remember that while the appeal letter is important, it is only one part of a successful appeal. Think of it as a helpful guide that your plan administrator (and, if necessary, the federal judge) can use to navigate all of the documents you are providing as part of your appeal. The letter, by itself, no matter how well-written or thorough, will not suffice in convincing the plan administrator to rescind its initial decision.
How do I prepare for writing the appeal letter?
Before you can write an effective appeal letter, you must first know:
- The deadlines you must meet
- Exactly to whom you must address all correspondence
- Specifically what is required by the plan administrator in the appeal
- Why your initial claim was denied
Uncertainty and lack of clarity are your enemies in preparing an ERISA appeal. Unfortunately, plan administrators can be frustratingly brief, and sometimes even vague, in providing their reasons for denying a claim for disability benefits. According to ERISA, plan administrators must indicate their specific reasons for rejecting a claim in a denial letter, detailing the plan provisions and any internal policies used to arrive at the adverse ruling. Despite this, most denial letters are relatively short and generic in nature.
The surest way to write an appeal letter that addresses all of the pertinent points of the claim denial is to request a copy of the administrative record beforehand. ERISA guarantees you the right of access to all of the documentation in the administrative record, including plan documents, benefit policies, medical records, employment records, analyses and reports prepared by or for the plan administrator, relevant telephone logs and emails, and other data and information relevant to your case.
How do I write the best possible appeal letter?
First, it is important to note that your appeal letter should be written to a very high standard. A sloppy, disorganized appeal letter filled with spelling and grammatical errors will only harm your chances of winning your appeal.
In addition, a strong appeal letter will include:
- Clear, concise information about you, the ERISA plan in question, and your claim that had been denied.
- A specific summation of your appeal and the decision or decisions you are contesting.
- A precise statement as to what you hope to achieve through the appeals process.
- A straightforward explanation of why you are appealing the decision, being sure to mention all relevant facts and details.
- An introduction to the evidentiary documents you are including in your appeal, along with a table of contents so that each document can easily be located.
- A conclusion that summarizes your points and expresses gratitude for the consideration of your appeal.
While you will want the letter to be as concise as possible, avoiding unnecessary detail and undue repetition, you also want to make sure that it is comprehensive. Don’t leave important details out simply because you want to keep your letter brief.This is your only real opportunity to state your case. If your appeal is denied andyou do pursue ERISA litigation, the appeal letter will be the closest thing to an opening statement that you will be afforded.
Is there anything I should not include in my appeal letter?
In developing your appeal letter, you will want to stick to the facts and your general argument against the claim denial. You are not a medical expert, so don’t pretend to be one; your opinions regarding your health and condition do not hold as much weight as your doctor’s. It is a great idea, however, to summarize your doctor’s opinions in your letter and point out where they can be read in full in your appeal.
Likewise, you will not want your letter to rely too heavily on appeals to emotion. While it is appropriate to describe the physical, mental, and emotional hardships you have faced as a result of your debilitating injury, this description should be secondary to the facts of your case. You do not want to get weighted down in sentimentality, as this tack will not find favor with the plan administrator or a federal judge. (Remember that these parties may feel compassion toward you and still rule against you based on the strength of your evidence, or lack thereof.)
In general, the appeal letter should not be the primary source of any evidence you are providing. Even something as seemingly simple as a description of your job should not be left to the appeal letter alone. The brief job description contained in your appeal letter should point to a more thorough and well-documented description included with your other evidentiary documents.
Ultimately, the best way to ensure that your appeal letter is as strong and persuasive as possible is to enlist the assistance of a legal professional who has a history of drafting successful appeal letters on behalf of a variety of clients. J. Price McNamara is just such a professional, and he would be pleased to put his experience and skill to work for you.