The timeline from application to a decision on a long-term disability claim is generally set by the terms of the plan itself. But disability policies that are governed by the Employee Retirement Income Security Act of 1974 (ERISA) must adhere to the Department of Labor’s ERISA claims regulations, which include timelines for issuing a decision on an application. Most disability policies issued by an insurance company to a private employer are governed by ERISA.
ERISA Long Term Disability Claims Regulations
The ERISA Claims Regulations, 29 CFR § 2560.503-1, provide that a benefit plan has an obligation “to establish and maintain a reasonable claims procedure” and set minimum standards for meeting that obligation. Included as part of those minimum standards are timelines for providing a decision on an initial claim application. For disability claims, a plan administrator must:
notify the claimant . . . of the plan’s adverse benefit determination within a reasonable period of time, but not later than 45 days after receipt of the claim by the plan.
However, the claims regulations further provide that:
This period may be extended by the plan for up to 30 days, provided that the plan administrator both determines that such an extension is necessary due to matters beyond the control of the plan and notifies the claimant, prior to the expiration of the initial 45-day period, of the circumstances requiring the extension of time and the date by which the plan expects to render a decision. If, prior to the end of the first 30-day extension period, the Administrator determines that, due to matters beyond the control of the plan, a decision cannot be rendered within that extension period, the period for making the determination may be extended for up to an additional 30 days, provided that the plan administrator notifies the claimant, prior to the expiration of the first 30-day extension period, of the circumstances requiring the extension and the date as of which the plan expects to render a decision.
“Matters beyond the control of the plan” may include waiting for information or records from a treating physician, waiting for information regarding eligibility from the employer, and other reasonable circumstances related to gathering information to establish an entitlement to benefits.
Follow-up regularly to find out if you are approved for disability
With the initial 45-day window and the two possible 30-day extensions, a decision may take up to 105 days and still comply with ERISA regulations. It is therefore in every applicant’s best interest to be proactive as possible in helping the insurer or plan administrator reach a decision. Our firm always encourages applicants to follow up regularly after their claim application is submitted and request statements of exactly what information is missing from the file so that any follow-up can be made as soon as possible.