How to Win Denial of Health Benefit Litigation – Part 2 .


Not all health benefit claims are insured. Some may be legitimately denied by the insurer. To the extent the claim is insured and the insurer wrongfully denies coverage, you may have to litigate to enforce your rights. The key to winning denial of health benefit litigation is to first recognize the burden and then assume it. Part I of these materials provided a candid review of the burden placed upon participants to enforce their group health care benefits governed by the Employee Retirement Income Security Act of 1974 (“ERISA”) through the interpreted cases of the United States Sixth Circuit Court of Appeals.1 The playing field is not level between insurer and insured. ERISA favors the insurer.

Part I established the administrative phase of benefit enforcement to be critical because the courts will defer to the insurer’s discretion in determining benefit coverage at the litigation phase. The key to winning claim denial litigation is to create a detailed, methodical and rational evidentiary record during the administration of your claim which can be used later to persuade the court that the insurer’s discretion and reasoning are flawed.

Part II shall provide some practical guidelines to gathering evidence needed to turn the tide in favor of enforcing your health benefit rights. These appeals can be very complicated and technical so you may want to retain counsel to assist. If you choose to handle your own appeal, you may want to consider the suggestions.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

© Eric Skidmore, Skidmore & Associates, L.P.A. | Attorney Advertising

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