ERISA Claims Process and Appeals Procedures for Long-Term Disability

What Is ERISA?

The Employee Retirement Income Security Act (ERISA) provides minimum federal guidelines for pension plans and other benefits provided by private employers in the United States. Federal law does not require employers to offer any particular benefits, but ERISA rules control what happens if the employer chooses to offer benefits.

Here, we look at a general overview of the claims process and appeals procedures in ERISA disability claims.

The ERISA Claims Process

  1. The first thing you should do is contact your employer’s human resources department for your disability insurance plan’s specific procedure details. Do not simply make this request verbally. Make the request in writing.  Your disability insurance company should send you a written procedure or application for free.
     
  2. Make sure you note any deadlines to file the claim.
     
  3. File the claim before the deadline.
     
  4. The insurance company may request additional information in order to make a determination on the claim. The insurer will advise you of any deadlines to submit the additional information.  Remember it is your burden to prove you have a disability. It is not the insurance company’s burden to prove you are not disabled. Therefore, provide whatever documentation necessary to satisfy your “burden of proof.”
     
  5. If you are approved, then you will start drawing your benefits.  If you are denied, your insurance company should advise you of its decision in writing.  If you received a denial, you have the right to appeal the decision.
     
  6. Make sure to note any deadlines to file your appeal. The deadline is likely in the insurance company’s denial letter.
     
  7. File your formal notice of appeal within the time limits, typically 180 days.
     
  8. The insurance company will again review your appeal, and will issue a new decision.  If your claim is approved, you will begin to draw your benefits and any past-due benefits. If you are denied, then the insurance company should advise you of your appeal rights in the denial letter.
     
  9. Once you have exhausted all of your administrative appeals, you have the right to file a lawsuit in federal court, challenging the insurance company’s wrongful denial of your claim.