Denied ERISA Short-Term Disability Benefits? Follow This Appeal Checklist
No one wants to get a claim denial letter from the insurance company for their short-term disability benefits. Unfortunately, it’s a far too common occurrence.
Many people with legitimate disability insurance claims are denied benefits and then have to appeal their insurer’s decision. If you’re thinking about filing an appeal with your short-term disability carrier, you need to have a plan — otherwise, you may make mistakes that could reduce or even eliminate your benefits.
If your short-term disability benefits are employer-funded, a federal law called ERISA (Employee Retirement Income Security Act of 1974) applies to your claim. This law sets out specific procedures that you must follow during your appeal.
This article will focus on short-term ERISA claims; if your short-term disability policy is private or self-funded, contact our office for help. Our team also handles appeals for long-term disability benefits and are ready to help if you are facing an unfair denial.
ERISA vs Non-ERISA Disability Appeals: The Main Differences
Most disability insurance policies sponsored by private employers, organizations, or other groups are governed by ERISA regulations. The policies are often very uniform and offer little variation from policyholder to policyholder and must follow certain rules that are particularly strict about the appeal process.
ERISA policies put significant limitations on when and how you can file appeals. If you disagree with the denial, you’ll need to need to file an appeal directly with the insurance company within 180 days of receiving the denial letter, and you’ll need to fully exhaust all your administrative appeals options (which may even include a second appeal) before you can file a lawsuit against the insurer or plan administrator.
Even if you do file a lawsuit, you will not have a right to a jury trial but will have your case decided directly by a judge. Worse, if you forget a key piece of information until after the administrative appeals process is complete, you will be barred from presenting new evidence. This means you essentially need to build a full case in an extremely short window of time. If you plan on presenting information in stages, that must be clearly stated at the beginning, or else you run the risk of being denied the opportunity to present a full case.
By contrast, those with non-ERISA individual policies typically don’t have to jump through as many hoops before they can file a civil action in state or federal courts. They also tend to have a much more open-ended structure to the lawsuit process, offering much more time to properly investigate, prepare, and present a case in court.
Overall, ERISA cases require appellants to act fast and don’t allow for mistakes, so be sure to get the help you need early on.
Step 1: Review Your Insurance Denial Letter
When the insurance adjuster denies your short-term disability claim, they must provide you with a detailed explanation for their decision. A simple “you’ve been denied” is insufficient under federal law.
Instead, your denial letter should outline:
- The specific reason why the adjuster denied your disability claim, such as lack of supporting medical evidence
- Basic information about how to file an appeal
- Your appeal deadlines
This information is essential to your short-term disability appeal, since it will help you understand the issues with your claim as well as how much time you have to prepare an appeal. If you need any help understanding this information, contact a short-term disability lawyer right away.
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Step 2: Understand Your Disability Insurance Policy’s Deadlines and Procedures
While your denial letter should outline the basic appeal deadlines and procedures that apply to your claim, you should also review your Plan Document or Summary Plan Description (SPD). These documents outline all the timelines, deadlines, and the precise procedures that you must follow during your claim.
Why should you spend so much time reviewing your short-term disability insurance policy’s procedures? ERISA claims require a lot of attention to detail, and a simple mistake could cost you your disability insurance benefits. To reduce the risk of a mistake, you should carefully read these documents, identify all of the deadlines, and set reminders so you don’t miss a due date.
Unfortunately, many Plan Documents and SPDs are filled with dense legal language, which makes them hard for a non-lawyer to read and interpret. If you’re having a hard time understanding the precise terms and conditions of your disability plan, you should talk with an experienced disability lawyer. We can help you translate everything into plain language and suggest ways you can strengthen your claim.
Don’t put off your appeal; most short-term disability plans only give you 180 days to file an appeal and supplement your evidence. This means you don’t have time to wait to contact an experienced disability lawyer, and makes early intervention all the more important.
Step 3: Schedule a Consultation With a Disability Lawyer
ERISA appeals are complicated and involve extremely strict procedures. While you can file an appeal on your own, it’s in your best interest to consult a lawyer. A short-term disability attorney can help you navigate your appeal and understand your legal arguments. During an initial consultation, you’ll meet with a lawyer who will review your documents, ask questions about your medical conditions and disability claim, and provide practical legal advice.
When it comes to short-term disability appeals, sooner is always better when it comes to contacting an experienced disability attorney. The earlier the intervention, the more time you have to prepare and the higher your likelihood of success when filing your appeal. An experienced lawyer can help communicate with your insurance company on your behalf, gather and analyze evidence, and even file a short-term disability denial lawsuit if your insurance refuses your appeal and you’ve exhausted all administrative options.
At Bryant Legal Group, we offer free, no-risk consultations, so there’s no reason to wait to talk with an experienced attorney from our team. As Chicago’s premier disability law firm, we know the do’s and don’ts of filing short-term disability appeals and can help you avoid any costly mistakes.
Step 4: Request Your Claim File and Supplement It
When you send the adjuster your medical records and other evidence, this information becomes part of the claim administrator or insurer’s claim file. This file is an essential part of your ERISA claim, because it is often the only information that the adjuster or a federal judge can consider during your appeal. However, you only have a limited amount of time to submit additional evidence.
Once your insurance company-level appeal ends, your claim file closes, and you cannot give the insurer or a federal judge additional information. So, during your initial appeal with the insurance company, you need to provide them with as much supporting evidence as possible.
Common forms of evidence in a short-term disability appeal include:
- Medical records from all your doctors, hospitals, and other medical providers
- Diagnostic reports, like MRIs, CT scans, EKGs, and sleep studies
- Mental health records from therapists, psychologists, and counselors
- A résumé that outlines your education, training, and work experience
- Your job description and other work-related information
- Letters from your doctors that carefully explain your limitations and ability to work
- Opinions from doctors, vocational experts, and other specialists
- Written statements about your symptoms and capabilities from either you or trusted loved ones
When you review your administrative record, look for missing information. Then, quickly request those records and send them to the insurance adjuster.
Step 5: Submit Your Written Appeal to the Insurance Company
When you want to appeal the insurance company’s denial, you typically need to do so in writing—a phone call isn’t enough. While you may send a simple letter that says, “I am appealing your decision,” that’s rarely sufficient. An experienced disability insurance lawyer can help you create a detailed appeal letter that outlines your factual and legal arguments.
Denied After Appealing to the Insurance Company? You Can Appeal Again
Even if you send the insurance company a well-written appeal letter and lots of new medical records, there’s a good chance they will still deny your appeal. Every day, insurers deny claims from people who are legitimately disabled. Fortunately, you have options even after an appeal denial.
When the insurance company denies an appeal, they must notify you in writing. Once you get their denial letter, you and your ERISA lawyer can file a federal lawsuit. While you cannot demand a jury trial, you will be able to present written arguments to a federal judge. In these arguments, you can explain your case and prove you’re eligible for short-term disability benefits.
Your ERISA Short-Term Disability Appeal Checklist
If you’re working with a disability insurance attorney, they will perform many of these tasks for you.
Review your denial letter. Identify the reason why the insurance company denied your claim.
Review your insurance policy’s appeal procedures and deadlines. Mark the filing deadlines in your calendar.
Consult a disability insurance lawyer who can educate you about your appeal options.
Request a copy of your claim file from the insurance company or third-party administrator for your employer’s short term disability benefit plan.
Determine whether the claim file is missing information about your medical conditions and disability claim.
Order the relevant records and provide them to the insurance company.
Write a detailed appeal letter and send it before your appeal deadline.
Review the insurance company’s final decision and assess your legal options.
Bryant Legal Group: Standing Up to Disability Insurance Companies
At Bryant Legal Group, we focus our practice on helping our clients with their disability benefits and other insurance claims. Our ERISA attorneys handle appeals at both the administrative and federal court levels, taking a practical, client-centered approach. If you have questions about an appeal, contact our office today.
The content provided here is for informational purposes only and should not be construed as legal advice on any subject.
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