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What are the timelines for an ERISA disability appeal?

Wednesday, October 4th, 2017

When a person becomes too injured or ill to work, disability benefits can serve as a means for keeping them afloat financially. For those in Garden City who have disability benefits through their employer, it is important to understand that these benefits are protected by the Employee Retirement Income Security Act of 1974 (ERISA). There are laws and rules with regards to the processing of a claim for benefits and what a person can do if his or her claim for benefits is denied.

For example, decisions on disability claims must be made within 45 days of the plan receiving the request for benefits. However, if there are circumstances beyond the control of the plan, the plan may have an additional 30 days to make a decision.

If a person’s claim for disability benefits is denied, the administrator of the plan must notify the person, through written or electronic means, with a sufficiently detailed explanation of the denial and how the person can proceed with an appeal. The plan must also provide the person with a description of what exclusions, guidelines or rules that were used in making their decision. Upon request, the plan must also give the person copies of the relevant documents at no cost.

A person whose disability benefit claim is denied has at least 180 days to appeal the denial. An appeal can include additional evidence for consideration. Once the appeal is filed, a person other than the one who made the initial decision will examine the information and will also consult with a medical professional. For disability claims, a plan has up to 45 days to review an appeal. However, if there are special circumstances, a plan may have up to 45 more days to review a claim.

There are, of course exceptions to the 45-day time period rules. One is if there is a collective-bargaining grievance process in place addressing disability claim appeal timelines. Another is if two levels of review are necessary. In that case, each review must be completed within 50 percent of the time limit that would be permissible if there was only a single review.

If a person’s disability claim is denied on appeal, it may be time to seek the advice of an attorney. This may be especially useful if a person suspects there was an ERISA violation. In the end, when it comes to disability benefits, it is important to understand the applicable timelines, so that appropriate action can be taken.

Source: United States Department of Labor, “Filing a Claim for Your Health or Disability Benefits,” accessed Sept. 30, 2017

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