What would seem to be a simple process at a critical time is complicated when the life insurance is provided through an employer. ERISA governs the procedures and typically the courts give the claim administrator deference if there is a denial of claim for proceeds from the life insurance policy.

Those making claims are required to “exhaust administrative remedies” by completing a review or appeal of any claim denial prior to filing suit to obtain benefits. It is critical to present all evidence to support a death benefit claim during the appeal process. Court rulings have prohibited consideration of evidence in support of a claim that was not presented to the review entity designated by the plan.

Issues that have been resolved through court cases regarding life insurance include: Denials based on pre-existing conditions at the time of basic coverage enrollment-typically supplemental coverage during open enrollment has less stringent criteria for coverage or eliminates pre-existing conditions; interpretation of exclusions or limitations based on whether death resulted from accident or illness, or intentional conduct; changes in coverage due to the employer transferring life benefits to a new insurance company; determining whether one was disabled and entitled to a waiver of premiums as a result of the disability; and simple negligence where an employer failed to turn in supplemental coverage election forms or failed to pay premiums.

If you need representation to make a claim for life insurance benefits, whether you need assistance with the review or appeal of a denial or making a formal claim in federal court please call Bogin, Munns & Munns at 407-578-1334.