The ERISA disability claims process is a procedure for employees seeking disability benefits through their employer-provided insurance plans. Managing this process involves several key steps, from understanding your policy and filing a claim to handling potential denials and appeals.
Knowing what to expect can help you track the benefits you should receive under the Employee Retirement Income Security Act (ERISA) and what to do if your claim is denied. If an insurer did not approve your claim, our ERISA lawyer can review your legal options during a free consultation.
What Is ERISA?
The Employee Retirement Income Security Act (ERISA) is a federal law enacted in 1974 that protects your benefits from employer-provided retirement plans, health insurance plans, disability insurance, and other employee benefit plans.
It sets rules to make sure these plans are managed fairly and that you receive important information about your benefits. It also gives you the right to sue if you believe an insurance company unfairly denied your benefits or mismanaged your plan.
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Who does ERISA Cover?
ERISA covers most private sector employees who participate in employer-sponsored retirement and health benefit plans. This includes plans that businesses, corporations, and nonprofit organizations offer.
It does not cover government employees or plans that churches offer. ERISA usually does not cover employees of state and local governments and many public school employees.
Additionally, ERISA does not apply to plans set up solely for the benefit of a business owner or their spouse.
Filing an ERISA Disability Claim: How does It Work?
To file an ERISA disability claim, follow these steps:
- Obtain the claim forms from your employer or insurance company.
- Complete the forms with accurate information about your disability and job.
- Collect all necessary documents to accompany your claim, such as your medical records, employer statements about how your condition prevents you from working, and your statement about how your disability affects you daily.
- Send the completed forms and documents to the insurance company or your employer.
You can mail or electronically submit your ERISA claim forms and documents directly to the insurance company that handles your disability plan.
Some employers may handle the submission process for you. Check with your human resources department for specific instructions.
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What Happens After You File an ERISA Disability Claim?
Understanding what happens after you file your ERISA claims process can help you manage your claim and prepare for any challenges. Here’s an overview of what to expect after filing your application:
Initial Application
Once you file your initial application, the insurance company has 45 days to decide whether to approve your claim. This deadline can be extended where notice is given.
Per the Code of Federal Regulations (CFR), specifically 29 CFR § 2560.503-1, a deadline extension can be an additional 30 days if the insurance company notifies you and provides a valid reason for the delay. They can request a second 30-day extension if necessary.
Administrative Appeal (if Denied)
If the insurance company denies your initial application, you can submit an appeal directly to the insurance company. You have 180 days from the date of the denial notice to appeal an ERISA disability claim. After that period, the insurance company has from 45 to 105 days to decide on your appeal.
This time frame includes an initial 45 days and a possible extension of 60 days if necessary. Under most policies, you can appeal twice.
File a Lawsuit
If you sue, you must file your lawsuit in Federal District Court within three years from the date proof of loss is due. However, check your policy’s terms, as this period might vary.
You also must exhaust all administrative remedies, meaning you must complete the appeal process, before you can take legal action. Exhausting administrative remedies allows the insurance company the opportunity to review and potentially correct any mistakes internally.
It also gives the insurer time to potentially resolve the issue without the need for litigation.
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How a Lawyer Can Help You With an ERISA Claim Denial
If your ERISA disability claim is denied, you can hire a disability insurance lawyer with our firm to manage this complex process for you.
As your lawyers, we can help you understand why your claim was denied, gather additional medical records and other proof to support your case and meet all deadlines so we can file your appeal on time.
We can also write a detailed appeal letter and negotiate with the insurance company on your behalf. If the appeal fails, we can represent you in court and argue your case there. While we handle your case, you can focus on your health and well-being.
A Denial Notice Must State Why the Insurer Didn’t Approve Your Claim
The insurance company’s written notice of denial must explain the specific reasons it denied your claim. It should also mention the plan provisions on which the denial is based and include information about your right to appeal its decision.
It is important to note that the administrative appeal is the only opportunity you will have to submit evidence of your disability for the record. If you must pursue a lawsuit later, the court will consider only the evidence that was submitted during the appeal period.
What to Know Before You Appeal an ERISA Claim Denial
The process for ERISA disability claims can be challenging, and it can feel like the process will not be in your favor. There are several reasons for this, including the following:
- Complex federal laws and regulations govern the process, which can make it hard to understand.
- Insurance companies have extensive resources and experience handling ERISA claims. They can use this to their advantage, making it tough for people to have a successful claim.
- Missing the strict deadlines for filing claims and appeals can mean losing your benefits, so you must stay on top of filing them on time. This is another area where our lawyers can help.
- Claimants bear the burden of proving their disability. This requires comprehensive and detailed medical evidence, which can be challenging to compile and present, especially because the court will look only at the evidence submitted if your case goes to trial.
These are just some of the reasons it can be daunting to pursue your case to prove you should receive disability benefits. Still, you can get help from a disability insurance attorney from our firm. We know ERISA law and have over 30 years of experience handling these claims.
Call Us Today for Help With the ERISA Disability Claims Process
The ERISA disability claims process can be confusing and frustrating for claimants. With so much at stake, including your financial security and well-being, it can be worth it to get professional legal help with your claim.
An ERISA lawyer from Marc Whitehead & Associates will use decades of legal knowledge and support to help you through the claims process and secure the benefits you deserve. Call us today to discuss your situation during a free consultation.
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