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Steps to appealing your ERISA disability claim denial

| Feb 11, 2019 | Firm News

If you recently applied for ERISA disability insurance and the insurance company denied your claim, you may be frustrated. Perhaps you are wondering what to do next. The first thing you should know is that you have a limited amount of time to appeal their decision. You must act quickly. Although each policy is slightly different, here are the steps you must take to appeal your ERISA disability claim denial:

Read your denial thoroughly. If the plan administrator or insurance company denies your claim, they must give you a written notice that includes the reason, and the notice must be understandable. Only after you understand the reason for the denial can you hope to respond effectively. You may want to consider hiring an experienced ERISA attorney to do this.

File your first appeal. The law requires a claimant to submit at least one administrative appeal in response to the insurance company’s denial. Some insurance companies require two administrative appeals. You will normally have at least 180 days to file your appeal, but you must gather a considerable amount of information in that time.

As part of the administrative appeal, this firm collects and prepares:

  • An appeal letter of 50 to 100 pages;
  • Letter from your doctor, as necessary;
  • Declaration(s) from you and others familiar with your functionality before and after your condition became disabling;
  • Articles about your medical condition;
  • New information in your medical records;
  • Allegations regarding the insurance company’s unfair denial.

After the appeal is submitted:

The administrator makes a decision. The administrator has 45 days to consider the appeal in a disability case, but is entitled to an extension of another 45 days. The insurance company often utilizes the exentsion.

During the review process, the insurance company will obtain new medical and vocational reports. The insurance company is required to provide the claimant with a copy of those reports and give adequate response time to the claimant before it makes a decision on appeal.

Your long term disability insurer may require more than one appeal. In this case, if the insurance carrier denies your first appeal, you may have to file a second appeal. Your timeframe will depend upon the policy, so pay close attention to when you must file your appeal.

File a lawsuit. Once the administrator or insurance company has denied all of your appeals, you have exhausted your administrative remedies. You may then file a lawsuit in court. All the work you did for your appeal will be very important at this stage, since your evidence in court will almost certainly be limited to the evidence you submitted during the appeal process.

If your employer’s disability insurance carrier denies your ERISA claim or terminates your ERISA disability benefits, the appeal process is an extremely important part of obtaining or re-gaining the benefits you deserve.