If you end up in a situation where you are unable to work due to a sudden or lingering disability, you may already have benefits provided by your employer as part of an employee benefit plan. These long-term disability benefits exist to help ensure you receive a basic level of income until and if you are able to return to work.
However, if you have never filed for long-term disability, it is very likely that you are not aware of the timelines that matter to your claim. Roy Law Group is here to help.
ERISA regulations are the rulebook for employee benefit claims
ERISA, or the Employee Retirement Income Security Act of 1974, regulates the responsibilities of those managing and administering employer-provided disability benefit plans.
ERISA was established to protect employees. It has binding rules that employers and insurance companies must adhere to, which include reviewing and deciding on applications for benefits or appeals of unfavorable disability claim denials.
You’ve submitted an application for benefits – now what?
Here is what you can expect after applying for benefits (as of March 2019; these regulations change from time to time):
- ERISA requires that upon your initial application for long-term disability benefits that your insurer has up to 45 days to approve or deny your application.
- Your insurer can delay this, with reason, by requesting an extension of up to 30 days. If your insurer requires this extension, they should provide the reason why and specifically identify what they need in order to make a final determination.
- If the insurer needs information from you, you have 45 days to respond with whatever information the insurer claims to require.
- Once your insurer has received the additional information they require, they have no more than 30 days to make a determination.
The shortest path through the initial application process is if your insurer does not need additional information to make a determination. In that case, you could have a decision in less than 45 days. However, if there are reasons your insurer needs to delay making a decision, you could be waiting several months or more.
If you get a denial or unfavorable response from your insurance provider
After the determination has been made, if you are denied or find your determination unfavorable, you have up to 180 days to file an appeal. Under ERISA, you must meet this deadline. If you fail to appeal within the time period prescribed, your case is over, and you have no further legal recourse against the insurance company.
This is the point in the process where you must hire an ERISA disability lawyer to represent you.
Why you need a lawyer for your disability appeal
Under ERISA, if you meet your appeal deadline yet your appeal is unsuccessful, you are allowed to seek judicial review of the appeal denial in a federal district court. However, the court is generally only allowed to review the information contained in the insurance company’s claim file. If the information is not in the file, the court will never see it. Therefore, preparing your disability appeal to be identical to preparing your case for litigation is critical.
From this stage forward, everything must be done with potential litigation in mind. If you haven’t done so already, this would be a good time to talk to a lawyer who understands ERISA law.
Timeline for an ERISA disability appeal
Here is how the appeals process typically works:
- If you receive an unfavorable response to your claim, you can request an appeal, and your long-term benefits insurer has 45 days to decide on the appeal.
- As with your initial application, if the insurer needs it, they can have up to 45 days more to make a determination with an explanation of why they need that time.
- If an insurer requires additional information necessary for a full and fair review of your claim, they may be allowed in some situations to pause that time period for the appeal until the necessary information is obtained.
- If your appeal is decided unfavorably, some plans require a second appeal prior to further legal action. Just like the first appeal, if a second appeal is required, you must meet the second appeal deadline or forfeit your right to judicial review.
If you need legal advice, call Roy Law Group
Roy Law Group works in the area of disability law and nothing else. If you are struggling to get the long-term disability benefits you deserve, contact Roy Law Group. Our team of compassionate attorneys and support people are here to help you settle or win your case.
Contact us today for your consultation.