FILING AN ERISA CLAIM
HOW TO FILE A CLAIM: A STEP BY STEP GUIDE
Whether you are filing an initial claim for benefits under your disability insurance plan or filing an appeal, the following information should be helpful to you. The information is provided to help you understand the disability claim process, and to give you some basic tips on how the process works and how to protect yourself in the early stages of your disability claim.
Disclaimer: The material contained herein is general in nature and may not apply to your particular factual or legal circumstances. You should not rely upon this information as a basis for making decisions about your case, your choice of attorney, or how to proceed with your claim. Internet subscribers and online readers should not act on this information without seeking professional counsel. Please read the “Disclaimed” at the bottom of this page.
STEP 1: GET A COMPLETE COPY OF YOUR PLAN DOCUMENTS
Your first task is to get a copy of your group disability plan. You should ask for the complete policy, although you may only be offered a Summary Plan Description. This is a summary of your group insurance plan that should contain the key provisions you need to understand.
You may be able to find a copy of the Summary Plan Description in your files, as many employers distribute this document. You may be able to find it on a company web site. Wherever you find it, you want to make sure it is the applicable version.
If you can’t find a copy, call the Human Resource Department of your employer. There is often a benefits coordinator in this department who can help you get a copy. You may also be referred to the plan administrator — this may be your employer, or may be another company designated in the summary plan description.
Whatever you do, do not wait long to receive this important document. Delays by other people may be your problem, not theirs. You can make your initial request by telephone, but if you do not receive the document promptly, you should make a written request by certified mail, return receipt requested. It’s an extra expense and hassle, but it could help you meet your crucial deadline period for filing an appeal, or show that you were not at fault.
You will have some protection from delays if your plan falls under ERISA law. The plan administrator must provide certain documents to participants within 30 days of a request, or potentially face monetary penalties for failure to do so. But it’s better to get your documents rather than rely on this legal protection.
STEP 2: READ YOUR PLAN
Your first step is to find out if you qualify for long term disability benefits. You want to look at the definition of disability to see if you qualify. It’s not enough to be sick.
You and your physician will have to demonstrate that your illness or injury makes you disabled according to the definition in your plan. Different plans have different definitions of disability, and most policies may have more than one definition that applies at different stages. You also need to see if you fit the criteria for eligibility. Depending on the plan, you may have to be a full-time employee, complete a minimum length of service, or make certain financial contributions.
Some illnesses or injuries fall under policy exclusions. The most common problem is a pre-existing medical condition. Other common exclusions are self-inflicted injuries, acts of war, riots, and other unusual situations. Many plans exclude injuries or illnesses covered by workers’ compensation benefits.
Even if your illness or injury is covered by the policy, it may have a limited period of benefits.
You also have to make sure that you have followed the appropriate procedures. This is a very common area where claimants make mistakes. Many policies have requirements about filing for short term disability, coordinating benefits with state or federal government benefit programs, medical treatment procedures, filing deadlines, and so forth. The right attorney can be very helpful in advising you of your rights and responsibilities in this area.
Above all, remember that you must understand your policy very well at the time you file a claim. Once you begin the process, the insurance company starts to compile what is known as an administrative record, and all your actions and statements can end up in that record. You want to make sure that everything in the record supports your claim.
STEP 3: START A DISABILITY CLAIM JOURNAL
It can be very confusing trying to manage your disability claim. Whether or not you have hired an attorney, you have initiated a process in which actions and statements have legal ramifications. A written journal can help you keep a clear record, and also help you track the path of your disability claim. This journal is for your private use and should not be given to anyone but your attorney.
You should record the date and manner of all requests for information, as well as communications you receive from your employer or your insurance company. Save copies of all written documents, organized by date. You should also track the path of your disability, including all symptoms that might impact your ability to work. You should request a copy of your medical records, and record the dates of medical visits and tests and test results.
STEP 4: CONSULT WITH YOUR PHYSICIANS
The strength of your claim has a close relationship to the input from your physicians. Often you have seen one or more doctors by the time you realize you might have to miss work for extended periods of time. You have tried to find a doctor who will give you the best medical care.
As you prepare to file a disability claim, you have to examine your relationship with your physician. The strongest disability case will be supported by a physician who believes that you are truly disabled, is highly credible to the insurance company, and is willing to be a strong patient advocate. Let’s take a look at each of these considerations.
First, your physician must believe that you are disabled. You are obviously sick, or you would not be going for treatment. This does not mean, however, that you are disabled according to the definition of your insurance policy.
You should review with your physician the ways in which your illness interferes with your ability to perform the tasks that make up your job. If you are at the “any occupation” stage of your policy, you will also have to review how your illness limits you from functioning in a broader range of jobs. Make sure you ask your physician to explain any aspects of your medical condition that can grow to become a bigger obstacle to work in the future. If the two of you agree on the nature of your disability, you have a good starting point for your claim.
While you are talking to your doctor, it is also a good time to learn about his or her familiarity with the disability claim process, and his or her willingness to be a strong patient advocate. Doctors don’t relish the idea of spending a long time documenting your disability. They often have to fill out papers, talk on the phone, and attend meetings. They may have their judgment questioned by other physicians loyal to the insurance company. Most of them will accept this inconvenience as a disagreeable necessity, although some physicians are beginning to charge separate fees to fill out claim forms. A minority of physicians will resent helping you obtain benefits and will not follow through on your behalf.
If you sense that your physician is reluctant to get involved with a disability claim, it is perfectly appropriate to look for a second opinion from another physician that you think is more willing to be your advocate. You don’t want to compromise your treatment, of course, but in many cases you will have a choice of one or more competent physicians.
For the disability claim process, you want to be backed by a physician who is a specialist in your medical condition. It is also helpful if they have good medical credentials, as indicated by their education and training, or the quality of the medical facilities where they practice. Fortunately, this is the same type of physician that is likely to give you good medical treatment as well. We recognize that you may be emotionally tied to your physician, or you may be too overwhelmed or exhausted by your illness to consider another physician. This is another stage of the process where the right attorney can help you get the medical advocacy you need.
STEP 5: FILE YOUR DISABILITY CLAIM
Now that you have mastered your insurance policy, started your claim journal, and worked with your physician to define your disability, you’re finally ready to file your claim.
In most cases, you begin by filing a claim for Short Term Disability benefits. You can request claim forms as outlined in your plan documents, and your physician will need to fill out his or her portion of the claim form.
Your plan administrator typically gives you little guidance regarding the information you should provide to support your disability claim. We recommend that you add to the claim file any information that reasonably supports your claim. This includes medical records, relevant excerpts from your claim journal, written statements from your co-workers, written statements from family and friends, general information relating to your disability, and anything else that you think will help to educate the plan administrator regarding the nature of your disability.
STEP 6: WAIT FOR THE DECISION
If your plan is governed by ERISA law, the insurance company must approve or deny your claim within a reasonable time. If it has not made a decision in the first 60-90 days (see the language of your plan), it will typically notify you that it needs additional time to make a determination, usually because it need additional medical records or the information. Under ERISA law you will usually be notified in writing of the insurance company’s decision.
STEP 7: IF BENEFITS ARE DENIED
If you If your plan is governed by ERISA law, the insurance company must approve or denied, you will be notified of your right to file an appeal with the insurance company or administrators and told that – for new disability claims – you have 180 days to do so. It is, at this point, that you should call The ERISA Law Group.