Why the appeal comes before the lawsuit
Most employer-sponsored benefit plans are governed by ERISA, and before filing suit you usually have to complete the plan's internal appeal. The denial letter should explain the reasons and the deadline to appeal, and that deadline is usually applied strictly. In many cases the court later reviews the decision based on the record assembled during that appeal, and adding new evidence afterward can be difficult. That makes the appeal the most important stage for many claimants, not a formality. Medical records, statements from treating doctors, vocational information, and responses to the plan's own reviewers are often submitted then.
How a court reviews the decision
If the plan gives the administrator discretion to interpret its terms, courts often apply a deferential standard and ask whether the decision was reasonable, rather than deciding the claim from scratch. New York restricts discretionary clauses in many insurance policies issued in the state, which can change that standard for insured plans, though the analysis depends on the plan and where it was issued. Conflicts of interest, such as an insurer that both decides claims and pays them, can also be weighed. Remedies are generally limited to the benefits owed, and claims are typically decided by a judge on the papers rather than by a jury. Some plans set their own limitation period for filing suit.
What to bring us
Bring the denial letter, the policy or summary plan description, and any correspondence with the insurer or plan administrator. You can request a copy of the claim file and the plan documents, and that request is worth making early. If you have already filed an appeal, bring a copy of everything you submitted. In a first meeting we look at the deadlines, whether the plan is covered by ERISA at all, since government and church plans often are not, and what evidence the record still needs.
