Understanding the ERISA Appeal Process and Your Rights: How Long Do You Have to Appeal an ERISA Long Term Disability Benefits Denial?

Note: this guidance applies to appeals denied after June 9, 2023. If your appeal was denied before this date, please speak with an experienced ERISA attorney to help determine your appeal date as deadlines under ERISA were tolled during the National Emergency and will vary.

Introduction:

The Employee Retirement Income Security Act (ERISA) was enacted to protect the interests of employees participating in employer-sponsored welfare and pension benefit plans. These plans, which include pensions, health insurance, and disability benefits, must adhere to strict guidelines outlined in ERISA. However, there are instances when a claim for benefits is denied, leaving individuals with the need to appeal the decision. It is essential to understand the timelines and processes involved in appealing an ERISA denial to protect your rights and secure the benefits you deserve.

The Initial Long-term Disability Benefit Denial:

When a claim for ERISA benefits is denied, the plan administrator is required to provide a written notice explaining the reasons for the denial. This notice must include the specific plan provisions that were relied upon, as well as the appropriate steps for filing an appeal. Typically, you will have 180 days from the date of the denial notice to submit an appeal.

The Appeals Process:

Submitting an appeal is a required step in challenging an ERISA denial. The appeal allows you to present additional evidence and arguments to support your claim. To ensure a successful appeal, it is important not only to understand and adhere to the process outlined by your specific benefit plan but to respond to the denial with evidence that supports your disability.

• Review the denial notice: Carefully read the denial notice to understand the reasons for the denial and any specific requirements for the appeal process.
• Gather supporting documentation: Collect all relevant documents, including medical records, expert opinions, and any additional evidence that can strengthen your case.
• Follow the plan’s appeal procedure: ERISA requires benefit plans to establish a formal appeals process. This process may involve submitting written statements, supporting documents, and any other requested information. Adhere to the specific instructions provided by the plan.
• Meet deadlines: Ensure that your appeal is submitted within the prescribed timeframe. Failure to do so may result in your appeal being dismissed and could result in the loss of your right to file a lawsuit in federal court.
• Engage legal assistance: While not mandatory, seeking legal counsel experienced in ERISA appeals can provide valuable guidance and increase your chances of a successful outcome. An experienced ERISA attorney will be able to guide you in ensuring that you gather the right evidence to respond to the bases for the denial. Moreover, in most cases, the appeal is the only opportunity you will have to submit evidence that a judge would see, were your claim to go to court. While there are some exceptions, this is a very important consideration.

Timeframe for Decision:

Regarding disability appeals, once your appeal is submitted, the plan administrator has 45 days to review the appeal and make a determination or to notify you in writing of a “good reason” for taking a one-time extension of an additional 45 days in which to render its decision. This written notice must be provided to you before the initial 45-day deadline expires. Since this extension is almost always taken, you should plan on 90 days before you will have a decision.

Review and Rebuttal:

During the review period, the plan administrator will likely develop medical and vocational evidence in its review of your appeal. Under federal regulations, you are entitled to a copy of any reports upon which the plan administrator will rely in denying your appeal. This is a chance to respond to these reports before the appeal is denied. You will likely be provided with very little time to respond – 7 to 10 days. Your first step should be to contact the plan administrator in writing and request an extension. Note that any extension you are granted will be added on to the plan administrator’s deadline to provide you with a decision. This is another situation in which engaging an experienced ERISA attorney can be helpful. He or she will be able to advise you on (a) whether to respond at all (in some cases, the reports may be favorable to you); and if so, (b) what the response should consist of and include.

Legal Recourse:

If your ERISA long-term disability appeal is ultimately denied, or the plan administrator fails to respond within the designated time frame, you have the option to pursue legal action. ERISA allows you to file a lawsuit in federal court to challenge the denial of benefits. It is important to note that you must exhaust all administrative remedies by completing the appeals process before taking legal action. At this stage, legal representation, while not required, is absolutely essential.

Conclusion:

Navigating the ERISA appeals process for a denial requires careful attention to deadlines, procedures, and documentation. It is crucial to be proactive and diligent in asserting your rights to ensure you have the best chance of overturning the denial. Seeking legal assistance is strongly recommended at the appeal stage and beyond. ERISA appeals can be complex, and legal professionals with expertise in this area can provide valuable guidance. Remember, understanding your rights and following the proper procedures can significantly increase your chances of a successful outcome when appealing an ERISA denial.