Augusta Erisa Disability Plans Attorneys Explain Claiming Benefits
The Employee Retirement Income Security Act of 1974 (ERISA) is a complex federal law administered by the U.S. Department of Labor. It contains provisions affecting several employee benefits plans. Although it mostly focuses on retirement, or pension, plans, it also includes guidance for disability insurance plans provided by private companies and unions.
ERISA Disability Plans
ERISA generally covers pension plans offered by private employers and unions; however, it also applies to non-pension fringe benefits plans called “employee welfare benefit plans.” Disability insurance plans qualify as an employee welfare benefit. Basically, it requires employers to maintain such plans in a straightforward manner while providing complete and full disclosure to participants.
In general, ERISA sets forth requirements for the following aspects of disability insurance plans:
Disclosures – ERISA requires certain disclosures to be provided to plan participants, including among other things, a written plan summary, rules for obtaining disability benefits, and limitations.
Protection – ERISA is a safeguard for participants. Those who manage and administer disability insurance plans are prohibited from discrimination or other actions that are not in the best interest of plan participants.
Reporting – Disability insurance plans are accountable to and must report certain details to the federal government on a regular basis.
Who Must Comply With ERISA?
ERISA applies to disability plans of private employers and unions that were established after January 1, 1975. All disability plans developed before that date are independent of ERISA; although, they still have to comply with some state and federal laws.
ERISA does not mandate that companies offer disability insurance plans. It simply establishes guidelines for those employers who choose to offer them to employees. Disability plans made available to local, state, and federal government employees are exempt. Churches and many other religious organizations are also exempt from ERISA regulations.
How To File A Claim Under An ERISA Disability Plan
If you become disabled, you may make a claim for insurance benefits under your ERISA disability plan. One requirement is that your plan provides you with written details about how to make such a claim. Many disability plans will allow you to begin a claim online, via telephone, via fax, or through the mail with a paper form.
Your plan will likely require the following information when you initiate a disability claim:
Personal information – Your name, date of birth, and Social Security number
Employment information – Your employee ID, insurance group ID and number, and dates of eligibility for insurance benefits
Claim form – A form provided by the insurance company that begins a claim for benefits
Medical eligibility information – A statement from your doctor or medical service provider, medical records, office notes, verifiable test results, or medical evaluations
Even if you file a claim online or via phone, you will likely have to submit medical information via mail or fax. Your insurance company may also require that your medical provider send them records.
You have a right to know each step of the claims process. If you are confused at any point, you should contact your disability insurance company and ask for a written statement of the process. Someone should also be available to explain the process to you.
If Your Claim Is Denied
If your disability claim was denied and you disagree, you may file an appeal with the insurance company. You must be provided a written denial with an explanation of why you were denied benefits. You then have the opportunity to appeal that denial. A written letter asking for reconsideration is usually not enough. You may need to submit additional medical evidence, scholarly research, and certified statements from doctors to prove that you qualify for disability benefits. Your appeal is time sensitive. If you do not submit your appeal by the deadline, you waive your right to appeal.
Processing Your Claim and Appeals
One of the primary functions of ERISA is to ensure your benefits claim is processed in an efficient manner. It imposes time limits and requirements on your insurance company for making decisions at each step of the claims and appeals process.
Making a Decision – Disability claims must be processed and decided within a “reasonable period of time,” but not more than 45 days after a claim was received. If the plan cannot make a determination within 45 days for reasons outside of its control (e.g. if your doctor does not provide medical records within that time), then it must notify you of that reason within the allotted period of time.
Appealing a Denial – You have at least 180 days to appeal a denial of your claim for disability benefits. Your plan must provide you with the name and contact information of any experts whose advice was obtained in reviewing your claim, as well as any documents or records that were used to evaluate your claim. Upon appeal, you may submit additional information and address any reasons that your original claim was denied.
Review of Appeal – Your insurance company must assign someone new to review your appeal, and who must consult with qualified medical experts. Your request for reconsideration must be reviewed within a “reasonable period of time,” but not more than 45 days after receipt of your appeal. Collectively bargained plans, often negotiated by unions, may have different time periods to which they must adhere.
Secondary Review – Your plan may require you to complete two levels of review before the final decision process on appeal. The second review must still take place within the initial 45 days. Thus, each reviewer essentially has half the time limit to review your claim.
Denial of Appeal – If your appeal is denied, you may need to file a lawsuit against the company. You would essentially be asking the court to declare that you are entitled to benefits under the requirements of the disability plan. You may also be able to seek an external review if your plan was issued in or after 2010. Seek the advice of an ERISA expert to decide which option is better for you.
If you feel you have been wrongfully denied ERISA disability plan benefits, or your rights have been violated in another way, contact the Augusta ERISA disability plan attorneys today.