FindLaw KnowledgeBasePublished: 2012-05-03
Many employer-provided health plans include long-term disability insurance, which provides employees with benefits equal to a portion of their income if they become unable to work because of a disability. In most cases, these insurance plans are governed by a federal law known as the Employee Retirement Income Security Act of 1974, or ERISA. Unfortunately, ERISA is notoriously complicated and many people encounter obstacles during the claims process.
To help your claims process go as smoothly as possible, it is important to review the details of your insurance plan before filing a claim for disability benefits. Read your plan carefully to make sure you meet the requirements to receive benefits and understand what you must include in your application. After you file a claim, the provider must approve or deny it within a reasonable time, or no more than 45 days.
If Your Claim Is Denied
An ERISA disability claim may be denied for a number of reasons. In some cases, the administrator may state that your disability is not covered by your insurance plan, or your application may have been filled out incompletely or incorrectly.
Regardless of the stated reason for the denial of your claim, it may still be possible for you to obtain benefits, and you have a right to appeal the decision. However, you must take action quickly after your claim is denied, because applicants usually have just 180 days to file an appeal after receiving notice of a denial of benefits.
When you file an appeal on a denied ERISA disability claim, your claim will be reviewed by an administrator other than the person who denied your original claim. By law, this must occur within a reasonable time after the administrator receives your request for review. In most cases, this means that the review must be conducted within 45 days, although certain exceptions apply.
If Your Appeal Is Denied
If the insurance plan denies your claim on appeal, this is referred to as a “final denial.” After receiving a final denial, you may choose file a lawsuit in court to challenge the decision. For assistance with a disability claim or appeal, or to discuss your legal options for pursuing a claim after a final denial, contact an experienced disability insurance lawyer.