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Components of an ERISA Disability Insurance Claim

Under your employer-sponsored disability policy, you are entitled to income replacement benefits if you are disabled and unable to work due to an injury or sickness. However, recovering on the policy may involve navigating a multistep process. Below is a summary of different components to a claim for disability benefits.

Step 1: Filing Your ERISA Long-Term Disability Claim

First, Gather and request all relevant medical and occupational information. Your employer may need to provide information regarding your occupational duties and salary information. Health care providers may take anywhere from a few days to a few weeks to transmit your medical records. In the meantime, speak with your physicians/therapists about certifying your disability status in a letter to the insurer or by completion of an Attending Physician Form. Then obtain the required claim forms/plan documents from your employer. Your policy contains a description of your benefits, the definition of “disability” and applicable timelines for when to submit claims and expect decisions. Often, the plan administrator will request your medical and occupational information from your health care providers and employer, but you should maintain open lines of communication with these parties to confirm the documents are provided in a timely manner, so your claim is not delayed. Secondly, speak with your providers about certifying your disability status in a letter to the insurer. Make sure your providers understand your specific occupational duties, so that they can present a clear picture of how your disability prevents you from performing these duties. Third, keep copies of the documents you submitted, note when you submitted them and any communications you have with the insurer. Finally, if your policy specifies deadlines for filing suit, mark the dates on your calendar.

Step 2: Monitoring Your ERISA Long-Term Disability Claim

Refer to your policy for specific timeframes. Most insurers will take 45 days to issue decisions on disability claims, and in many cases, will request one or more 45-day extensions. If you do not receive any updates within the specified time period, contact your insurer for a status update. However, if you still do not receive any response beyond 45 days after the insurer received all the relevant information on your claim, consult with an experienced ERISA attorney to assess whether you can file suit based on the plan’s failure to establish or follow for claims procedures.

Step 3: Appealing an ERISA Long-Term Disability Claim Denial

If your ERISA disability claim is denied, you should receive a written denial letter from the insurer explaining the reasons for the denial. Common reasons include a lack of supporting medical documentation, or the insurer’s determination that a medical condition is not severe enough to be disabling. The denial letter may also offer guidance on what additional documents you need to submit. Typically, you have 180 days from the denial date to request an administrative appeal, or a review of your claim. If necessary, request an extension of this deadline. Mark this date on your calendar, as your failure to request an appeal by the deadline will constitute a waiver of your future rights to dispute the decision. Consult with an ERISA attorney to ensure your appeal is complete and all the relevant documents are submitted to the insurer to support your claim. As to why Often times, the insurer will not tell you that the appeal is your last chance to submit documentation needed to prove your disability claim in litigation. An attorney can make sure all deadlines are met, and your claim file is complete so you have a strong case in litigation.

To read our article on why to hire an attorney for your appeal, click here.

Step 4: Bringing Suit to Recover Your ERISA Long-Term Disability Benefits

After your appeal is denied, you may bring a suit in federal court against the plan administrator or more typically, against the claims administrator (the insurer denying the claim) for benefits, attorneys’ fees, pre-judgment interest and costs. If you have not yet done so, consult with an experienced ERISA attorney to help you file suit. Because many attorneys are unfamiliar with the intricacies of ERISA regulations and/or litigating in federal court, you should find an attorney who specializes in handling ERISA cases.

McKennon Law Group PC is extremely well suited to litigate your ERISA disability, health or life insurance claims. We are nationally recognized experts in insurance bad faith law and ERISA insurance claims appeals and litigation. With offices in Los Angeles, Orange County, San Francisco, and San Diego, contact us today to learn how our attorneys can help you with your ERISA and bad faith insurance claims.

For additional information, please see our ERISA FAQs and Disability Insurance FAQs.

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Phone: 800-682-4137

We also have offices in Los Angeles, San Diego and San Francisco.

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