Having a long-term injury or illness is devastating on many fronts. First, the physical impact may require lengthy and expensive medical treatment. Second is the financial toll it can take, especially if your condition keeps you from working. And third, the emotional strain.
That stress only gets worse if you file a long-term disability (LTD) claim under your employer’s plan, but it’s denied by the insurance company administering benefits. Many people are at a loss over what to do next. That’s where the federal Employee Retirement Income Security Act (ERISA) can help get an insurer’s denial overturned.
What must the insurance company do?
After denying your claim, the insurer will send you a notice by mail or electronically, which must include the following information:
- The complete justification for the denial, explaining why they disagree with a doctor or other expert’s diagnosis.
- They must refer to specific provisions in the plan for basing their denial.
- They must tell you that you have the right to obtain, free of charge, copies of all documents relevant to your case.
- They must explain all the criteria they used for the denial. You can request a copy.
- Finally, they must explain the plan’s appeals process, including deadlines and a statement that you can take them to court if your appeal is denied.
If you filed the initial claim on your own, it’s advisable to consult with a long-term disability lawyer specializing in ERISA law before pursuing an appeal.
How the appeals process works
LTD claims are denied for various reasons, and insurers take advantage of every loophole to deny benefits. It might have been a paperwork error, or they didn’t have enough information about your injury. Regardless of their reasoning, you normally have 180 days under ERISA guidelines to appeal.
After receiving a denial, it’s essential to gather all medical documents from your doctor, hospitals and other healthcare providers you’ve seen about your condition. Having these documents handy for your lawyer can help speed up the appeals process.
Once they receive the appeal, the insurance company must review it within 45 days, but they can extend the deadline by another 45 days as long as the extension is justified. When this happens, they must notify you in writing with an explanation and specify the new date for a decision prior to the exhaustion of the initial 45-days.