When a person becomes seriously injured or ill, and cannot work for an extended period of time, they may be very thankful if they have disability insurance through their employer. These benefits can provide policyholders with the compensation they need to make ends meet until they can go back to work. However, in order to obtain such benefits, they will first need to file a claim with their insurer.
Before filing a claim, it can help for a policyholder to review their summary plan description and summary of benefits and coverage. This can help the policyholder understand what is required under the plan, and the procedures they should follow should they decide to file a claim for benefits.
After filing a claim, the policyholder will likely experience a waiting period before hearing back from their insurer. This waiting period could be anywhere between 72 hours to 45 days, depending on what kind of claim is filed.
If the insurer denies the policyholder’s claim, this denial must be in writing. It has to provide the policyholder with the reason the claim denied and what procedure the policyholder should follow to appeal the insurer’s decision.
A policyholder who wishes to appeal a denial of benefits has at a minimum 180 days to ask for a review of their claim. They should follow the appeal process laid out in their plan, and they may have to provide their insurer with further evidence or information to assist in the review of their claim. The review could take anywhere from 72 hours to 60 days.
Once the insurer makes a decision, it must provide the policyholder the reason the appeal was either approved or denied in writing. The insurer must also let the policyholder know if there are any additional levels of appeal, and it needs to inform the policyholder about the policyholder’s right to have the appeal reviewed by a judge.
If the policyholder believes the insurer violated their rights under the Employee Retirement Income Security Act of 1974 (ERISA), they may want to contact their area Employee Benefits Security Administration (EBSA) office for further information.
As this shows, filing a claim or appealing a denied claim is a nuanced process. It is important that no step is overlooked. Fortunately, there are professionals available to assist policyholders seek benefits under their disability insurance policy, so that the policyholder can pursue the financial compensation they need during a difficult time.
Source: dol.gov, “Filing a Claim for Your Health or Disability Benefits,” accessed Jan. 14, 2018