You employer-provided long term disability insurance is supposed to cover you when your mental or physical condition makes it impossible to work. But actually receiving benefits can often be challenging. Find out how to appeal if you have had your long term disability benefits denied or terminated.
This blog post will address the appeals process for employer-provided long term disability insurance policies under the Employee Retirement Income Security Act of 1974 (ERISA). It will explain an employee’s options when they have their long term disability benefits denied or terminated. It will also explain when it is time to hire an attorney to help.
When Will You Know Your Long Term Disability Benefits were Denied
Any long term disability matter starts with a claim for benefits. This is a written request sent to the plan administrator, or the employer’s human resources department. Employees facing long-term disabilities should consult their Summary Plan Description to see where the claim should be filed and what should be included.
In employer-provided policies, federal law gives insurers a deadline to respond to any claim. Initially, the plan must make a decision within 45 days of the filing of the claim. However, the plan can request up to two extensions and can request additional information from the employee, which may further delay the response. Plan administrators must give a written decision within 30 days of receiving the final information.
What to Look for in the Long Term Disability Benefits Denial
If your long term disability benefits are denied or terminated, the plan administrator must give you a written or electronic notice that provides:
- Why your claim was denied (including any disagreements with medical professionals or vocational experts)
- Which specific part of the plan the denial is based on
- Notice that you are entitled to receive all documents related to your claim at no cost
- Copies of the rules, policies, protocols, and other guidelines used in denying your claim
- Descriptions of the appeals process and time limits going forward
A careful review of the long term disability benefits denial notice can be the difference between a successful appeal and further frustration. Where the reason for the denial was insufficient medical documentation, or a lack of objective measurements for the effect of the disability, an appeal may simply mean the employee needs to provide further information. When the decision is based on a disagreement with medical professionals, the policies and protocols may provide insight into what more needs to be done to win the appeal.
When to File the First, Mandatory Appeal
ERISA requires long term disability insurers to include an appeals process in their plans. Employees have the right to have their claim reviewed by someone new who was not involved in the original denial. That person will take a fresh look at the claim and supporting documents. He or she is not allowed to consider the initial decision or the reason for the denial.
The policy’s Summary Plan Description and the written denial should each explain the time limits for filing your first appeal. Under ERISA, the plan must allow at least 180 days to file an appeal (but it could be longer). A decision on appeal can be based on any information provided along with the appeal itself, even if it was not a part of the original claim. If an employee’s condition has deteriorated during the six months or if a new doctor has provided additional diagnoses or work restrictions, they may be the basis for approval of benefits on appeal.
Once again, the plan is required to respond within 45 days and can request an extension of up to 45 days. The plan cannot deny benefits for a new reason, or based on a new medical report, unless it gives the employee notice of the new information and a reasonable opportunity to respond. The employee is also entitled to copies of any new evidence used in reviewing the appeal.
Union Workers May Have Different Appeals Processes
Employees who are part of a single-employer or multi-employer union may have different time limits or review processes written into their collective bargaining contract. When their long term disability benefits are denied they may have to follow their collective bargaining grievance process or wait for a quarterly board of trustee meeting.
Should You Hire an Attorney for the Second, Voluntary Appeal?
Some insurance companies provide a second level of administrative appeals, called either a second appeal or a voluntary appeal. If a voluntary appeal is available, the denial notice on the first long term disability benefits appeal will include information regarding the secondary appeal process and the time limits. Under ERISA, the employee must be given a reasonable amount of time to file a second appeal (sometimes less than 180 days). However, the plan still only has the same 45 days to address both levels of appeal.
Many employees choose to file a first or second appeal on their own, waiting to hire an attorney until the matter is headed to court. However, hiring an attorney for the mandatory or voluntary appeal gives that attorney a chance to review the bases for denying the claim and to provide additional proof, improving the chances that a claim will be granted and strengthening the case if it does head to court.
When an employee files an ERISA lawsuit after having their long term benefits denied, the court is typically only allowed to look at evidence provided during the administrative stages of the process. When employees wait to hire attorneys, they lose access to the professional experience of what it takes to develop their strongest case.
However, there are also reasons why an attorney may recommend skipping the voluntary appeal and heading straight to court — such as when the employer or plan administrator has made a mistake in its reason for the denial that may result in a favorable result in court. By consulting with a long-term disability lawyer before filing the second appeal, an employee may be able to shorten the process and receive their long term disability benefits sooner.
Employees with serious impairments often have their long term disability benefits denied by insurance companies. But no doesn’t have to mean no. By strategically filing a second appeal or federal lawsuit, employees can get the benefits they need to support themselves, and their loved ones. At Bross & Frankel, our long-term disability attorneys are here to help. We will review your denial and your condition, and help you make your strongest case. Contact us for a complimentary consultation.