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What If My ERISA Disability Claim Is Denied?
24August 16

What If My ERISA Disability Claim Is Denied?

Erisa Disability Claim Denials

If you have disability insurance from your private employer, chances are it must operate according to the Employee Retirement Income Security Act 1974 (ERISA). ERISA is a law administered by the U.S. Department of Labor and protects the participants of employee health and welfare plans that are provided by private companies. It provides guidance for disability insurance, as a welfare plan, offered by employers.

If your ERISA disability claim was denied, you may be concerned that your employer or insurance carrier violated ERISA. Contact our experienced disability lawyers with Uscher, Quiat, Uscher & Russo, P.C. at 1-800-797-5575 to find out how we can help you.

How Your Disability Plan Must Comply With ERISA

ERISA establishes requirements for private company disability plans to prevent discrimination and unfair treatment. It requires that participants receive information necessary to understand the plan and that the plan follows a set of standards when evaluating claims. When considering whether to approve or deny your claim, your disability plan must adhere to the following requirements:

  • Participants who are denied benefits must be notified of a grievance process to make complaints.
  • Participants must be made aware of the appeals process if they are denied benefits.
  • Participants have a right to sue the company for benefits when they have been wrongfully denied through an established appeals process.
  • If no appeals process is established, participants can sue the company for breach of duty as well as wrongful denial of benefits.
  • Participants have a right to receive written notification of why their claim was denied.
  • Participants have a right to submit additional evidence, including medical information, if they are initially denied.
  • The plan must comply with ERISA-established deadlines when processing claims.

Steps to Take If Your Disability Claim Was Denied

After making an initial application, your disability insurance provider has 45 days to make a decision regarding your benefits. If you are denied benefits, you must be notified within 45 days in writing. Your insurance company must provide you with detailed information about why you were denied and give you an opportunity to appeal its initial decision.

If your initial application is denied, you should seek the help of a disability attorney to ensure that you gather all of the appropriate information to seek approval upon appeal. You often need to provide additional medical information as well as legal arguments that you should qualify for benefits. A qualified disability attorney can help you through this process.

With the help of your attorney, you may take the following steps after an initial denial of your disability benefits:

  1. Appealing the Denial – You have 180 days within which you must file an appeal of the denial of your claim for disability benefits. You should carefully review the reasons listed by your insurer that you were denied and cater your response to those reasons. If your insurer did not receive enough information regarding the severity of your conditions, you should seek additional medical treatment that will provide that information. You may also seek a second medical opinion to support your claim. You should seek help from medical professionals who have experience working with the disability claims process. You may seek opinions from other experts, including vocational experts, rehabilitation advisors, and other professionals.
  2. Waiting on Review – Your claim will be reassigned to a new claims examiner for review. That examiner will look at all previously submitted evidence as well as anything new. The examiner will also consult with medical experts and may even request that you meet with a medical professional. You may have to wait up to 45 days for this initial review process to be completed.
  3. Requesting a Secondary Review – If the initial review process results in a denial, you may be able to request a reconsideration from your insurance company. You will be provided with additional information about why you were denied again, and you should obtain additional evidence that specifically addresses that denial. The secondary review process should also take place within the initial 45 days that ERISA established for an appeal review.
  4. Receiving a Final Denial – If you are denied at the final level of review by your insurance company, you may need to file a lawsuit against the company. You would be asking the court to evaluate the evidence you’ve presented to your insurance company in order to determine whether you are eligible for disability benefits. An ERISA disability lawyer can help you determine if a lawsuit is in your best interests.

Seeking Help to Appeal a Disability Denial

ERISA can be complicated, and it is not uncommon for disability insurance companies to fail to follow all of the requirements of the law. If you have experienced discrimination or unfair treatment while applying for disability, you should consider making a claim against the company. If you were wrongfully denied insurance benefits, you should appeal and even consider a lawsuit. Contact the disability lawyers with Uscher, Quiat, Uscher & Russo, P.C. at 1-800-797-5575.  Let us deal with the legal process while you focus on dealing with your health issues.

 

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