Claims Procedure General

Video: ERISA claims process overview and sub-topic on reimbursement provisions

The Importance of Appealing Denials and Terminations of Disability Benefits and What You Need To Do.

You can hear a podcast about this topic hosted by two ERISA attorneys here.

Appealing denials and terminations of disability benefits is absolutely crucial to having disability benefits reinstated. 

If your disability insurance is governed by the federal ERISA statute then failing to appeal a denial of benefits is fatal to your claim.  You have to appeal any denial or termination to the administrator of the claim (typically the insurer that denied it) and they must issue a final determination before you can go to court.  If you try to go to court before there has been a final determination the court will not hear your case because you have not yet ‘exhausted your administrative remedies.’  If your policy states that you must apply within 180 days (and virtually all such policies do) and you have failed to submit a timely appeal, then the administrator will not accept a late appeal and will not issue a final determination.  You claim for benefits is at that point dead.

You must file a timely appeal.  But you must also submit any and all documentation necessary to establish your disability as part of your appeal.  This is absolutely vital to wining an appeal.  Here is why:  If your appeal is denied and you go to court a judge, with few exceptions, will decide the case based on a review of the information the administrator had when it made its determination.  There will be no trial.  You will not be allowed to submit additional medical records or other evidence later.  You must do it during the appeal. 

The administrator of your claim is almost invariably the insurer that has to pay your benefits if you are found disabled.  They lose money if you win your claim.  It is your burden to establish your right to benefits.  Even if the administrator and its ‘representative’ tells you it is gathering medical records and requesting that your providers complete disability forms, it is ultimately your responsibility to submit evidence to support your claim.  An argument to a judge after the fact that “they were supposed to gather medical records” will not succeed.

Lawyers often obtain and submit many documents and reports in addition to medical records.  Narrative reports from physicians, specialized forms, affidavits from claimants and others, functional capacity examinations, neuropsychological exams, vocational assessments.  This article is not legal advice and you should consult an attorney who understands ERISA disability claims litigation as soon as possible if you have been denied disability benefits and are appealing that denial.