ERISA Claims and Appeals Process & Procedures

If your employer offers long-term disability benefits, it will typically be covered by a federal law known as ERISA (Employee Retirement Income Security Act). ERISA sets minimum standards for benefit plans in the private sector, offering a number of protections for individuals enrolled in these plans. In addition to grievance procedures and appeals processes, ERISA claim also requires plan administrators to establish specific claims procedures.

If you are unable to work due to a disability, ERISA regulations will play a substantial role in determining how you obtain benefits. Understanding ERISA and how it applies to your long-term disability claim can help you as you work through the process. An experienced New Jersey disability attorney can counsel you on the claim requirements based on your specific policy.

How ERISA Applies to the Disability Claims Process

A specific section of ERISA — 29 CFR §2560.503-1 —regulates claims procedures for benefits plans that are covered by the law. Plans providing disability benefits have an obligation to establish and maintain reasonable claims procedures. This includes:

• All ERISA claims procedures and all applicable time frames are included in the summary plan description;
• The appeals procedures do not include any provision that would inhibit a beneficiary from filing a claim (such as requiring a fee to file a claim);
• The claims procedures do not prevent an authorized representative from acting on behalf of a claimant; and
• The claims procedures have administrative processes and safeguards to ensure that determinations regarding benefits are made in accordance with the plan documents and that plan provisions have been applied consistently.

In addition, the claims procedures cannot require a claimant to file more than two appeals of a benefit determination before bringing a civil action under ERISA. The plan also cannot contain a provision for mandatory arbitration of benefit determinations (except if considered one of the two appeals described above, and in accordance with other ERISA regulations).

These regulations have a goal of making your long-term disability claim process fair, by ensuring that you can file a claim without having to pay a fee (for example) and that you don’t have to go through endless rounds of appeals before filing a lawsuit if your benefits claim is denied. In 2018, the Department of Labor (DOL) added new provisions to ERISA designed to address the changes that occurred after the implementation of the Affordable Care Act. These provisions apply to all claims filed on or after April 1, 2018.

In addition to the above requirements, all ERISA disability plan claim procedures must:

• Provide an “explanation of the basis for disagreeing with or not following” the “views” of treating and consulting medical and vocational specialists for adverse benefit and appeal determinations;
• Provide “Either the specific internal rules, guidelines, protocols, standards or other similar criteria of the plan relied upon in making the adverse determination or, alternatively, a statement that such rules, guidelines, protocols, standards or other similar criteria of the plan do not exist” for adverse benefit and appeal determinations;
• Provide “explanation of the basis for disagreeing with or not following” “SSDI determination” for adverse benefit and appeal determinations;
• Disclose to the claimant “any new or additional evidence considered, relied upon, or generated” by the plan “in connection with the claim”, as well as any “new or additional rationale.” These materials must be disclosed “as soon as possible and sufficiently in advance of the date on which the notice of adverse benefit determination on review is required … to give the claimant a reasonable opportunity to respond prior to that date” before making an adverse appeal determination;
• “Describe any applicable contractual limitations period that applies to the claimant’s right to bring such an action, including the calendar date on which the contractual limitations period expires for the claim” in appeal decision letters.

Most importantly, if a plan fails to strictly adhere to any of the claim procedures outlined under the ERISA rules, then a claimant can proceed immediately to a lawsuit. This is known as the “deemed exhausted” rule. There are some exceptions to this rule, which your New Jersey disability benefits attorney can explain to you.

Working within the ERISA Disability Claims Procedures

The updated ERISA regulations related to disability benefits claims procedures are generally considered favorable to claimants. For example, requiring plan administrators to explain the basis of their disagreement with treating specialists will give you or your lawyer a starting point for an appeal.

However, it is important to understand that regardless of the changes to the regulations, you must comply with the ERISA claims procedures set forth by your disability benefits plan. Just as the plan itself must follow the ERISA rules, you are required to follow the process outlined in your plan documents. A failure to do so may significantly limit or even prevent you from obtaining benefits.

For example, if your initial claim is denied, then you have a set period of time to file an appeal. Many plans have a 180-day deadline from the date of the denial to file an appeal together with any additional evidence. If you miss that deadline, then your only remaining option may be to file a lawsuit in federal court to seek benefits.

How a New Jersey Disability Benefits Attorney Can Help

The ERISA claims procedure can be confusing, particularly if you are already dealing with an illness or injury that requires you to devote your time and attention to your recovery. While the plan administrators are required to establish reasonable claims procedures and follow certain rules, you must also comply with the process set forth in the plan documents — or risk losing your ability to access benefits. If you are struggling with getting this done, a New Jersey disability attorney can work with you to put together a claim and handle any appeals, if necessary.

At Bross & Frankel, we are dedicated to working with individuals who are unable to work due to illness or injury. We are highly skilled at helping our clients through the ERISA claims procedure, from filing the initial claim to advocating for our clients at the appeals level, to filing a federal lawsuit if necessary. If you are considering filing a long-term disability benefits claim, contact our office today at 856-795-8880, or reach out online.