What Is The ERISA Disability Claims Process & Procedures?

The Employee Retirement Income Security Act (ERISA) is a federal law that sets the minimum standards for disability benefit plans in the private sector.

According to 29 CFR §2560.503-1, the plans that offer disability benefits must follow these ERISA Rules For Long-Term Disability Benefits Claim procedures:

• The summary plan description should include ERISA claims procedures and pertinent time frames
• An authorized representative should not be prevented from acting on behalf of a claimant
• There are certain checks and balances within the claims procedures to ensure that determinations regarding benefits are made according to the plan documents and applied consistently.

Further ERISA Disability Claims Regulations aim to keep the claims process fair and consistent. They ensure that you can file a claim without a fee and that you do not have to continually appeal before filing a lawsuit, if your claim is denied.

After April 1, 2018, New ERISA Regulations For Disability Claims and Appeals included:

• Give an explanation of the basis for disagreeing with treating or consulting medical and vocational specialists

• 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.

If an employer’s plan fails to adhere to the claim procedures, the claimant will be able to immediately file a lawsuit.

ERISA Rules For Long-Term Disability Benefits Claim Process

In addition to employers, insurance companies must also follow ERISA Disability Claims Procedures to ensure protection of disabled employees.

• Impartial decision-makers at every step
• Employment decisions separated from possibility of disability claims
• Denial of claims standards should be explained
• Explanation of disagreeing with doctors or Social Security Administration disability decisions
• All rules and guidelines used to make a determination must be included and explained
• Access to the scientific basis for their decisions
• Give you free access to your entire claim file
• Notify you if it uses new evidence or information in denying your claim
• Finish the whole appeals process within 45 days, with one 45-day extension
• Send denial notices in other languages when necessary

If employers and insurance companies do not follow the guidelines and procedures, claimants do you have built-in protections. The claimants may be able to sue the standards set forth by the Department of Labor are not met. Claimants can also sue when their claim is wrongfully denied.

ERISA Lawyer Explains What To Do When Disability is Denied

If your disability claim is denied, your best course of action to immediately contact an experienced ERISA Disability Lawyer. A lawyer will be able to walk you through the process of the ERISA Disability Appeal. A lawyer will be able to look over the application and pinpoint any inconsistencies or irregularities.

There is a timeline to the appeals process, so if you wait too long, you might be left with no recourse to recover your disability. You should review your benefit plan, your application, and the denial letter to see if you can identify why you were denied.

When you do file an appeal, you have the right to ask for a copy of any evidence used by the plan to determine denial of your claim. An experienced ERISA Long-Term Disability Lawyer can review your appeal in order to determine if all information that should be included actually is. If your appeal is denied, you might be able to sue for disability benefits. A lawyer can represent you in ERISA Disability Lawsuit Settlements.

If you have been denied and have questions about an ERISA Disability Appeal, contact an experienced ERISA Disability Lawyer at CJ Henry Law Firm, PLLC. If you are located in or near Ocala, FL, call (352) 577-7746 for a free consultation.