Long-term disability insurance is a valuable fringe benefit offered by many employers. If an employee becomes unable to work due to injury or sickness, disability payments can replace a large portion of lost earnings. Workers who file a disability insurance claim may build a stronger case by presenting all medical evidence to the plan administrator, rather than to a court.
Disability insurance provided by an employer is subject to the Employee Retirement Income Security Act, also known as ERISA. A specific timetable for the processing of disability claims is included in ERISA. If an initial claim is denied, it can be appealed to the plan administrator. A second administrative denial can be appealed in federal court, but the court will only consider evidence introduced at the administrative level.
Initial claim
Once you file an initial claim, the insurance plan administrator generally has 45 days to approve or deny the claim. The administrator may further delay the decision for 30 days under extenuating circumstances beyond their control. If the administrator requests more information, you then have at least 45 days to provide the information. Unless you are notified differently, your claim is then decided within 30 days after submitting the information.
Administrative appeal
If your initial claim is denied, it may be an indication that there is insufficient supporting evidence. You are allowed at least 180 days to file an administrative appeal with your plan. After the appeal is filed, the plan generally must reach a decision within 45 days. If there are extenuating circumstances, the plan is allowed an additional 45 days to approve or deny your claim.
Federal court case
If the administrative appeal is denied, your next option is to appeal the decision to federal court. Because of ERISA regulations, the federal court cannot consider new medical evidence. Only evidence generated during the administrative process is considered. For that reason, your case must be built as strongly as possible during the administrative appeal.
Submitted evidence should substantiate your specific claim. Instead of relying solely on standard forms from the insurance company, obtain reports and records from licensed medical professionals. The opinion of a medical specialist is likely to be more credible than that of a general practitioner. Submit any x-rays or other medical images to support your claim.
ERISA requires your plan administrator to provide you with copies of documents they have regarding your claim. By knowing what information is in your file, you are able to determine what additional information is needed. Contact an ERISA disability claims attorney like Iler and Iler for further assistance in filing or appealing your case.
Share16 November 2015
