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Resolution of a Standard ERISA Disability Claim

What should you do if you become disabled and unable work? For most people, the first step is to file for Social Security Disability. However, you may have additional options such as short-term and/or long-term disability insurance (STD and LTD, respectively) through your employer. This blog is designed to provide you with an overview of the process and answers to general questions such as how to apply and what to do if you’re denied. Subsequent blogs will dive deeper into each step and answer more specific questions.

Step 1: The Application

The first step is to determine if you have STD and/or LTD coverage by contacting your employer’s human resources department. They will be able to confirm your eligibility and provide you with applications for both benefits. It’s also a good idea to see if they have copies of the insurance policies. The application(s) itself generally consists of 3 parts: (1) Employee’s Statement. (2) Employer’s Statement, and (3) Attending Physician’s Statement (APS). While you are responsible for completing the first part, you should leave the Employer’s Statement with the human resources department for completion. You should take the APS to your next doctor appointment (DO NOT leave it at the front desk) where you will ask him/her to fill it out for your disability case. The completed forms are then submitted to the insurance company listed on the application (e.g., CIGNA, MetLife, Prudential, The Hartford, Unum, etc.). Said insurance company will process your application and issue a decision within approximately 45 days.

Of course, there are a few issues that may arise at this step such as which of your physicians you should give the APS to and what to do if your employer or physician refuses to complete their respective form. These will be discussed in a later blog entry.

Step 2: The Appeal

Once the insurance company has finished its review it will issue a letter explaining its decision. While everyone hopes their application will be immediately approved, it is entirely possible that you will be denied STD and/or LTD benefits. If this happens you must first avail yourself of the insurance policy’s internal review procedures. In other words, you must file an administrative appeal. The denial letter will give you instructions on how to accomplish this, such as the following: “If you do not agree with our denial, in whole or in part, and you wish to appeal our decision, you or your authorized representative must write to us within 180 days from the receipt of this letter. Your appeal letter should be signed, dated and clearly state your position. You may also submit written comments, documents, records and other information related to your claim.”

You are also entitled to receive, free of charge, reasonable access to, and copies of, all documents, records and other information relevant to your claim. To do this, simply write to the insurance company and demand, pursuant to the ERISA regulations, that it provide you with the full STD or LTD claim file and a copy of the policy. This request is best made immediately after you receive a denial letter, before you file your formal appeal.

Please note that some insurance policies allow you to file a second appeal. Sometimes this is required; however, it is usually voluntary. The second denial letter from the carrier will specify whether this second appeal is not mandatory, often with language such as: “What if You Do Not Agree with the Appeal Decision? A second appeal request is not required but will be accepted if you have different or additional information to submit.”

At this point you and your attorney must decide whether you should file a second voluntary appeal or simply file a lawsuit in federal court. This will be discussed further in a later posting.

Step 3: The Lawsuit

If the insurance company upholds its decision to deny you LTD benefits on appeal, and you have exhausted the appeals process, the next step is to file a lawsuit in federal court. This will also be noted in the denial letter: “You may bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974. Please be advised that we are closing your claim file at this time, and no further review will be conducted with respect to your claim.”

While you can proceed pro se, or without legal counsel, the litigation process in an ERISA action is tumultuous and difficult to navigate. It is also unique in that you are not entitled to a jury trial, you cannot testify or have your physicians testify, and you cannot introduce any new evidence. Instead, the Federal Court Judge assigned to the case will make a ruling based solely on the evidence the insurance company had in its possession when it denied your claim. We would therefore strongly encourage you to call the Soloway Law Firm as early on in the process as possible. The best time to call us for help is at the time of application but no later than after the initial denial of your claim. Then we have the opportunity to build the administrative record during the appeal process so that you have the best opportunity to win your administrative appeal or if necessary your federal lawsuit.

Please check back for additional blogs on these and other related topics.