5 Disability Lawyer’s Tips for ERISA Appeals

5 Disability Lawyer's Tips for ERISA APPEAL

 

ERISA stands for the Employee Retirement Income Security Act and is a comprehensive statute that regulates most employer-provided long-term disability policy. If you are in looking for to understand the process of ERISA claims, appeals, and your rights here are five tips from disability lawyers to help you out.

 

Tip 1: Understand The ERISA Claims Process From The 10k Foot Level

The process of filing a long-term disability claim on an ERISA governed policy has two basic components. The claimant must submit a claim for long-term disability, and if denied, the appeal of that denial must proceed through an administrative process defined within the policy by the policy provider (the insurer).

 

 Tip 2: Know What ERISA Governed Policies Must Do For You

ERISA governed policies must do the following in both claims and appeals for long-term disability:

  1. Provide adequate written notice of the reasons for adverse benefit determinations
  2. Create internal procedures for the review of those determinations

Failure in either of these areas is something an experienced ERISA disability lawyers will immediately recognize. They will help you make clear to your insurer that poor communication, not following the process required of them, and not having given your claim the detailed examination it was due are not reasons to deny you your benefits.

 

Tip 3: You Will Get Several Bites at the Apple

Federal courts require that an ERISA policy participant (someone with an ERISA governed Long-Term Disability policy) must avail themselves of the policy’s internal review procedure before bringing a lawsuit in court.

This requirement means that if a claim for long-term disability benefits is denied, you have the right to appeal and should file an administrative appeal with the administrator of the policy within 180 days.  You should also consider reaching out to a good ERISA disability lawyer!

 

Tip 4: The Policy Provider is Under a Timeline Too

When you file a long-term disability claim appeal with your insurance carrier, the claim should be evaluated within 45 days after it is received. There are ways the insurer can extend that timeline, but the extensions must have reasons – the insurer cannot simply sit on your appeal until they feel like handling it.  Here’s more information on the timelines required by ERISA for claim and appeal.

Infographic: ERISA Initial Long-Term Disability Application

Infographic: ERISA Initial Long-Term Disability Application Timeline

 

Tip 5: You Should Cross Your T’s and Dot Your I’s

Many claims are denied, and in truth, so are many of the appeals of these denials. It is imperative that you take a very strong approach to your long-term disability appeal. Here are items you need to consider when pursuing a strong and detailed appeal of your long-term disability denial:

  • Describe your medical condition and the impact it has had on your life. Be thorough.
  • Try to state plainly what and why any the prescribed medical service is needed for any aspect of your daily routine.
  • State the reason(s) why you believe your insurance policy covers the treatment or services necessary to sustain your current condition, and why that condition makes it so you cannot perform your previous employment, or any employment.  You’ll want to understand the types of long-term disability policies, as they may cover different levels of employment barriers.  Read more about Own Occupation and Any Occupation coverages, here.
  • If you have a good relationship with your doctor, ask them to review the appeal letter and make any necessary additional observations or statements.
  • Send all correspondence to your long-term disability insurer by certified mail with a return receipt requested. Make copies of all documents you have sent, if necessary.

 

Bonus Tip:  Start Considering Disability Lawyers You Want to Work With

Arguably, the most important tip.  Find, consult with, and retain an ERISA attorney to review your appeal. Once you have finished your appeal, you may not be able to introduce new information into your claim if it is denied again and you are forced to file a lawsuit to obtain your benefits.

About the Author
In 1998, Chris obtained his law degree from the University of Oregon, and in 1999, he accepted his first job as an attorney with the Washington State Attorney General’s Office. In 2000, Chris entered a private litigation practice in Vancouver, Washington. In private practice, Chris litigated a variety matters including administrative, criminal, real estate, construction, business, and insurance.