Understanding Why Life Insurance Claims Are Denied 
The first step in appealing a denied claim is understanding the reasons behind the denial. Life insurance companies are strict about the criteria they follow when processing claims. Common reasons for denial include eligibility issues, incomplete or incorrect documentation, pre-existing conditions, lapses in coverage, and material misrepresentations on the insurance application. By understanding the reason for the denial, you can begin to build a strategy for your appeal. Eligibility Issues
One of the primary reasons for a denied life insurance claim is eligibility. For FEGLI and ERISA policies, the eligibility requirements can be complex. If you are a federal employee and your claim is denied due to eligibility issues, it is important to review your employment status, policy enrollment dates, and any other factors that may affect eligibility.Documentation Gaps
Life insurance claims often require specific documentation to support your claim, including medical records, proof of eligibility, and policy details. Missing or incorrect documents can lead to a denial. It is essential to ensure that all necessary documentation is provided when filing a claim, and if something is missing, you must correct it during the appeal process.
Pre-existing Conditions
Many life insurance policies, including those governed by FEGLI and ERISA, may have exclusions for pre-existing medical conditions. If your claim was denied due to a pre-existing condition, reviewing the terms of your policy is essential to see if this reason is valid. Sometimes, these exclusions can be challenged, particularly if they were not clearly disclosed during the policy’s issuance.Policy Lapse
Another common reason for denial is a policy lapse due to missed premium payments. If your premiums were not paid on time or your policy lapsed for any reason, your claim might be denied. However, insurance providers are sometimes willing to reinstate a policy under specific circumstances, particularly if the lapse was caused by a mistake or extenuating circumstance.Misrepresentation on the Application
Life insurance applications often require disclosure of health history and other pertinent information. If the insurer believes there was a misrepresentation or omission, they may deny the claim. Misrepresentation can include failing to disclose a pre-existing medical condition or providing inaccurate information about your health. While insurers are within their rights to deny claims based on misrepresentation, you can appeal if you feel the denial was unjustified.
We contacted Trief & Olk to help us with a life insurance issue and Shelly Friedland was the attorney assigned to our case. Before Shelly took our case she explained to us that the likelihood of our success without going to court was possible but not likely. Unfortunately we did not get the outcome we had hoped for but it was our decision to not move forward and have our case litigated. Shelly is very knowledgeable and was very straight-forward in her assessment of our case as we moved forward. She was very patient and thorough in answering our questions. She always responded in a timely manner and listened to our concerns. We would certainly recommend Shelly and would use her firm again in the future.”
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If there is any possibility of winning your life insurance case – this is the place to do it for you. They are efficient, honest and will achieve the best possible outcome.
Shelly Friedland worked on my case where a life insurance policy had lapsed and was even a few days beyond the grace period. Farmers had rejected my claim twice and was unwilling to take a second look. Shelly was able to get them to pay the entire claim without going to court, and the full amount was deposited in my account within a couple months. Highest recommendation.”
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Steps to Take When Appealing a Denied FEGLI or ERISA Life Insurance Claim
Once you understand why your claim was denied, the next step is to begin the appeal process. Both FEGLI and ERISA life insurance plans provide specific procedures for filing an appeal. These procedures are important to follow to ensure that your appeal is considered.Request an Explanation for the Denial
Before filing an appeal, request a detailed explanation from the insurer. Understanding the exact reason for the denial is crucial for addressing the issue in your appeal. If the denial letter lacks details, ask for more information regarding the specific reasons for the denial and the documents or requirements needed for a successful appeal.Review Your Policy
Once you have received the denial letter and the explanation for the decision, review your insurance policy carefully. FEGLI and ERISA policies have specific terms, conditions, and exclusions. Make sure that the insurer’s decision aligns with the terms outlined in your policy. If the insurer has made a mistake in interpreting the policy, you may be able to challenge their decision.Settlements & Verdicts
Gather Supporting Documentation
To strengthen your appeal, gather all relevant documents and evidence that support your case. This may include medical records, proof of coverage, proof of premium payments, or any correspondence that shows your eligibility or compliance with policy requirements. If a document was missing or incorrectly submitted with your original claim, ensure it is included in your appeal.Follow the Appeal Procedures
Both FEGLI and ERISA policies have specific procedures for filing an appeal. These procedures are set out by the insurer and often include deadlines for submitting your appeal. Missing deadlines or not following the proper procedures can result in your appeal being dismissed. Make sure to carefully follow the guidelines and submit your appeal within the designated time frame.Consult an Attorney
The appeals process for denied FEGLI or ERISA claims can be complicated, especially when dealing with complex legal terminology and procedures. Consulting with an experienced life insurance attorney can significantly improve your chances of success. An attorney who specializes in life insurance claims can help you navigate the appeal process, gather supporting evidence, and represent your interests to the insurer.The ERISA Appeal Process
ERISA provides specific protections for employees who are covered by employer-sponsored life insurance plans. If your claim is denied under an ERISA plan, you have the right to appeal the decision. The process is governed by federal law, and it provides specific steps for filing an appeal.ERISA Appeal Timelines
Under ERISA, you typically have 180 days to file an appeal after your claim is denied. It is crucial to file your appeal within this time frame, as failing to do so can forfeit your right to challenge the denial.De Novo Review
ERISA law requires that your appeal be reviewed independently by the insurer, without regard to the initial decision. This is called a de novo review, meaning the insurer will re-evaluate the facts and circumstances surrounding the claim. This process gives you an opportunity to present new evidence or clarify issues that were overlooked in the initial decision.Judicial Review
If your appeal is denied under ERISA, you have the right to take legal action. ERISA allows for judicial review, meaning you can ask a court to review the insurer’s decision. However, judicial review is limited, and the court will typically only evaluate whether the insurer followed the proper procedures and whether their decision was reasonable.The FEGLI Appeal Process
For federal employees who have life insurance through FEGLI, the appeals process is slightly different. FEGLI claims are administered by the Office of Federal Employees Group Life Insurance (OFEGLI). If your claim is denied, you can appeal the decision directly to OFEGLI.Filing an Appeal with OFEGLI
When you file an appeal with OFEGLI, you must submit all necessary documents, including medical records and proof of eligibility. OFEGLI will review your appeal and decide whether to approve or deny your claim.Federal Employee Rights Under FEGLI
As a federal employee, you are entitled to due process when it comes to challenging a life insurance claim denial. This means that you have the right to file an appeal and, in some cases, take the issue to federal court.Why You Should Consider Legal Help
Navigating the FEGLI or ERISA appeals process on your own can be challenging. With complex legal language, strict deadlines, and intricate procedures, having a legal expert on your side can make all the difference. Trief & Olk, a law firm with years of experience handling life insurance claim denials, can help guide you through every step of the process. Our attorneys will review your case, assist with gathering the necessary documentation, and ensure that your appeal is filed correctly.Appealing a denied FEGLI or ERISA life insurance claim can be a difficult and time-consuming process, but it is not an insurmountable challenge. By understanding the reasons behind your denial, following the proper procedures, and consulting with a skilled attorney, you can increase your chances of a successful appeal. Don’t let a denial prevent you from obtaining the life insurance benefits you’re entitled to. Trief & Olk is here to help, offering free consultations to help you navigate this complex process.