Now more than ever, Californians are concerned about what they will do if they need long-term disability insurance. This could come about due to an illness, injury or condition. When people are seeking disability benefits, the Employee Retirement Income Security Act (ERISA) is designed to protect them. It also sets guidelines for the administrators of the plan. Still, people can face a denied claim and be unsure of what they can do to successfully appeal the denial.
It is imperative to understand how to move forward with an appeal to get these critical benefits. Under ERISA, the insurer is granted a certain amount of time to decide on the claim. In general, once there is a claim, the decision will be given within 45 days. However, that could be extended based on the situation. If there is a denial, there is no need to panic immediately. It is wise to know what to do.
There will be a notice from the plan administrator as to why it was denied. In the notice, there will be a clear explanation regarding the reasons for a denial. The plan might disagree with experts who said the person was disabled. There could be a favorable disability decision from the Social Security Administration as part of the process and the plan administrator could also disagree with that. There may be provisions in the plan that say the person’s disability is not covered. The person can receive all documentation about the claim, the rules and other guidelines that led to the claim denial, and how to pursue an appeal.
Among the many reasons why a claim might be denied are not being eligible, or the need for more information to decide. The applicant has 180 days to appeal. The plan could give a longer time-period, depending on the circumstances. The information in the denial is crucial to the appeal and its effectiveness. With an appeal, a person who was uninvolved with the prior decision will assess the information. The previous decision will not be considered during the appeal. There will be up to 45 days for the appeal to be reviewed. Extensions are possible if the case warrants it.
It is possible to have a denial overturned on appeal. Even with that possibility, people who are confronted with this worrisome issue should be fully protected. These cases can be complicated and those who try to navigate them on their own will likely make costly mistakes. From the beginning, having legal assistance can be a fundamental part of a successful claim for long-term disability benefits under ERISA. It is a federal law, so this could lead to unexpected complications. Consulting with a firm experienced with denied insurance claims can be helpful.