Appealing the Denial of Long-Term Disability Benefits: The Basics

Appealing the Denial of Long-Term Disability Benefits: The Basics

When your employer-sponsored long-term-disability plan denies you benefits, you may be unaware of your rights under the Employee Retirement Security Income Act (ERISA), which is the federal law that likely governs your plan. Most importantly, you should be aware of your right to appeal the denial of benefits and understand how that process works.

Typically, an insurance company handles long-term disability claims for your plan, or if the plan is self-funded, then the claims may be administered by a private third-party claims company. Once you file a claim for benefits, the insurance company has 90 days in which to grant or deny your claim, although it sometimes will request an additional 90 days to review your medical evidence and process the claim. If the insurance company ultimately denies your claim, then you have the right to administratively appeal that denial of benefits. After a denial, an administrative appeal is often required before bringing legal action against the denying entity.

The first step of the appeal process is a pre-lawsuit administrative appeal that you file with the insurance company. An appeal should consist of new evidence, errors made in the denial letter, and other fats which support a reversal of the benefit denial. You should take care to file this administrative appeal in a timely manner, because most plans have strict timelines for filing appeals to the denial of claims for benefits.

It is common for the insurance company to request you to sign medical release forms, so you should cooperate in doing so. You also may wish to provide supplemental medical information directive from your medical providers. In participating in the administrative review process, you are creating an administrative record that the court can review if a further appeal is necessary. Applying for other disability benefits, such as Social Security Disability benefits, also may beneficial to you. A finding of disability by the Social Security Administration may be helpful to support your claim for long-term disability benefits.

If the insurance company denies your administrative appeal, you have the right to file a civil action in federal court challenging the denial of your long-term disability benefits. The federal court judge assigned to your case will review the administrative record before him or her, but the judge will not consider any new or additional evidence that is not already contained within the administrative record. If the court determines that the plan had no rational basis for denying the claim and that you were clearly entitled to benefits, then the court can rule that the denial of your claim was arbitrary and capricious, made in bad faith, or otherwise not supported by substantial evidence.

Appealing the denial of long-term disability claims can be complex matters that require intensive knowledge of ERISA law and how those laws affect long-term disability insurance policies. As a result, you will need experienced legal representation and advice to pursue an ERISA-governed disability claim. Bonnici Law Group is a law firm focusing on ERISA long-term disability benefits in Southern California. When you need effective legal representation, contact Bonnici Law Group at 619-259-5199 or email us at help@bonnicilawgroup.com.

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