Plan administrators have the authority under the ERISA statute to review initial ERISA long term disability claims and to deny claims. There is typically a procedure for submitting an initial claim that requires applicants to obtain attending physician reports from health care providers, fill out activities of daily living forms, sign authorizations so that the administrator can gather documents and contact health care providers directly, and other paperwork. Applicants often find this process tedious, and often experience delays.
Everything submitted to the insurer even at this early stage becomes part of the ‘claim file,’ which is what a judge would ultimately review if the plan administrator denies the claim and the matter ends up in federal court. It is therefore extremely important to establish your disability firmly during this process, and not to submit statements or other information that will damage your claim. Although the representative for the plan administrator may seem helpful, the reality is that they are working for a corporation that will save money if they can find a reasonable basis for denying the claim and should be expected to act in the best interest of the corporation and not the claimant.
Once an administrator has all of the necessary information and the application process is complete, it must notify the participant of an adverse decision within 45 days, but can extend that time period an additional 30 days if necessary for reasons beyond its control. If the administrator finds the applicant eligible for benefits (which presumably would happen within the same 45 or 45 + 30 day time frame), the participant typically has a continuing obligation to provide evidence of disability. This can take the form of providing medical records and/or authorizations, submitting to “independent” medical exams, being interviewed at their homes, etc. They are also often subject to video surveillance, especially in and around the time of “independent” exams and in home interviews.