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The Importance of ERISA Claim Appeals in Disability Benefit Claims

Qualifying for disability benefits often requires claimants to face many hurdles. An initial claim denial is not the end of the road, though. If you have group coverage, it is likely governed by ERISA, the Employee Retirement Income Security Act. One of the benefits of ERISA is that if a claim is denied, the claimant is statutorily entitled to a full and fair review of the denial. Taking advantage of that right and appealing the benefit denial is not only of critical importance in ultimately achieving success; it is a necessary precursor to filing a lawsuit to challenge the denial of benefits. And if done right, the claim will often be approved without the need for litigation. But even if the appeal is not immediately successful, it will set the stage for a successful benefit recovery in court. 

Be aware of timeframes

If you are seeking coverage under a plan offered under the Employee Retirement Income Security Act, there are certain critical requirements such as the limited time frame allowed to submit a claim appeal. And once an appeal is submitted, insurers have deadlines to decide appeals, which many courts strictly enforce. For disability claims, claimants are allowed 180 days from the date they receive notification of a claim denial to submit a claim appeal. That may seem to be a generous time allowance; however, the deadline can be difficult to meet if medical records need to be gathered and additional testing and vocational assessment is required. Therefore, it is critical for a claimant whose claim for benefits has been denied to contact an attorney immediately upon receipt of the claim determination.

Once an appeal is submitted, it must be decided within 45 days of receipt, although insurers are allowed a single 45 day extension to decide a claim appeal.

The Department of Labor has issued new regulations relating to disability benefits that will apply to claims submitted after April 1, 2018. Some of those regulations will significantly enhance the claimants’ opportunity to win on appeal due to new conflict of interest rules and most importantly, the right of the claimant to review and comment upon adverse evidence obtained during the claim appeal process before a final decision is issued.

ERISA claim appeals can be very complex and success in winning a claim is often dependent on consulting with an experienced attorney familiar with ERISA and its claim process and knowledgeable about disability benefits.

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DeBofsky, Sherman & Casciari, PC