Avoid delays during an ERISA long term disability claim or appeal

Communicating with your disability insurance company during an ERISA (the Employee Retirement Income Security Act) claim or appeal can become overwhelming and complicated. To avoid added stress and interruptions with your claim process, prepare yourself by becoming familiar with the terms and conditions of your plan or policy.  If you don’t have a copy, you should immediately request one from your insurance company or employer. Be mindful of time limitations governed by ERISA.  By reviewing your plan (or having someone review it with you), you will be in a much better position to support your claim and communicate effectively with the insurance company.  

  • Do not ignore the time limits of your plan! For example, you may see that your denial letter states that you have a minimum of 180 days to appeal an adverse determination regarding your disability claim.  If you miss this deadline, there is a very high likelihood you will lose your ability to file a lawsuit or have a judge decide the merits of your claim. 
  • Insist that your insurance company follow the rules of your plan! Your plan likely states that the insurer must decide the appeal within 45 days, or if “exceptional circumstances,” exist, may request an additional 45 day period to decide the appeal. 

Recently, Kantor & Kantor has seen insurance companies attempt to acquire more time by “tolling”, or suspending the time limits for an appeal decision. During this time, the insurance company theoretically obtains additional information from third parties (such as an “independent” medical examination).  Be aware that ERISA Regulations do permit an insurer to “toll” an initial claim while they request and wait for records or information. However, once a claim has been denied and it has been appealed, an insurer may not extend the deadlines simply by claiming that it needs additional information from third parties. 

We believe that any delay due to a request for third party information is an insufficient basis to “toll” the time for conducting an appeal and is an improper delay of the appeal process. The time for deciding an appeal may not be “tolled” unless the insured, not a third party, has failed to submit information to decide a claim. 29 C.F.R. 2560.503-h(i)(4).

As you gain a better understanding of your plan’s terms, you will be able to demand that your insurance company complies with the law and communicates with you in a timely manner. If you let them know that you are an educated consumer, it may compel them to attend to your claim more carefully.

Don’t lose valuable rights because you didn’t read your plan. Don’t let your insurance claims administrator take advantage of you, and delay the payment of your benefits longer than the law allows! If you have any questions about your long term disability claim or appeal, do not hesitate to call us at (800) 446-7529 for a no-cost consultation.