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How the ERISA Claim Process Works

Our Nationally Recognized ERISA Attorneys Help Individuals File & Appeal Disability Claims Across the Country

Thousands of people in the United States become disabled every year due to an illness or injury. If you have disability insurance through your employer or a union, you may qualify to seek disability benefits under the protection of the Employee Retirement Income Security Act (ERISA).

Understanding ERISA and disability law is an important component in collecting the benefits you need to pay your bills while you are disabled. That is why it is important to contact an ERISA attorney at Tucker Law Group as early in your claim process as possible. When seeking disability benefits, we use our experience to help you understand the ERISA claim process and collect the benefits you deserve.

What Is ERISA?

ERISA stands for the Employee Retirement Income Security Act. ERISA is a federal law that protects the interests of employee benefit plans and their participants. This federal law covers more than 684,000 retirement plans, 2.4 million health plans and 2.4 million additional benefit plans, all of them sponsored by private companies.

Is your employer-sponsored benefit plan covered by ERISA? If your benefit plan is offered by a private employer, your plan is covered by ERISA, not your state’s laws. ERISA still applies to your employer’s plan whether you or the employer pays the premiums for the insurance coverage.

If you are filing for disability insurance benefits, ERISA will also have a major impact on your long term and short term disability claims.

When filing an ERISA claim, there are many complex procedures that you as the claimant must follow to have your claim approved. Before filing a claim, it is important to understand the steps associated with the ERISA claim process.

The ERISA Claim Process

Handling an ERISA claim and the process as a whole can be difficult. At Tucker Law Group, our goal is to simplify this process for you. We will also help you develop the types of evidence needed to win your claim. Below, we outline the basic steps to help you understand the claim process and ERISA law.

Tucker Law Group Infographic How ERISA Claims Work

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The Initial Claim

Filing an ERISA claim is the first step towards collecting long term disability benefits. You will need to complete a series of forms and provide different types of documentation, including medical records. In addition, your employer and the attending physician must also complete several forms.

Insurance Company Investigation

Once you submit your claim, the insurance company will need to investigate. This involves reviewing evidence of your disability, including:

  • Claim forms
  • Medical records
  • Pharmacy records
  • Financial records
  • Attending physician statements

The insurance company may also require you to attend an examination with a doctor it chooses. Based on the investigation, the claims administrator will either approve or deny the claim. Under ERISA regulations, the insurer/administrator can legally take up to 105 days to decide your initial claim, so do not be surprised if it takes more than three months for a decision to be made. However, the insurer must ask for an extension after 45 days passes and if it does not send a letter asking for that extension, a lawsuit can be filed immediately.

Unfortunately, claims administrators routinely deny disability claims, even when there is clear evidence of disability. If that happens to you, it is important to appeal all claim denials after consulting with your ERISA lawyer.

The ERISA Appeals Process

If an employee is denied disability insurance benefits, the law requires you to file a mandatory appeal with the insurer. The law requires the insurance plan to give you a decision letter that includes certain information about why the claim was denied, in part so you have some of the information needed to file your appeal. This includes specific plan provisions or terms that were relied up, as well as an explanation of the evidence that was used to deny the claim. You have the right to request copies of documents, records and any information that is relevant to the claim for benefits. ERISA then allows up to 180 days for claimants to file an appeal. Filing an appeal is not only critical to the success of a disability insurance claim, it is MANDATORY.

If you miss your filing deadline (even by one day), then you will lose the right to receive your disability insurance benefits FOREVER. Further, your appeal must include all of the evidence you would ever want a court to consider. ERISA is a unique law, because it does not allow you to add new evidence once you get to court. As we explain below, if your appeal is denied, your case will be reviewed by a Judge on the paper that is in your claim file. There will not be a trial. For that reason, you want the assistance of an experienced ERISA attorney to help you through the appeals process. We can ensure that you do not miss any critical deadlines and help you create the required evidence to prove your case. Our attorneys can also help you understand what to expect from the ERISA appeal process.

Once the disability insurance plan receives your appeal, the insurer must make a determination within 45 days. However, the insurance company can get one automatic 45-day extension, allowing the insurer to take up to 90 days to decide your appeal. Also, if the insurer asks for documents or information from you, they will claim they are allowed to suspend or “toll” the deadlines until you respond to their request. With tolling, an insurer may claim it can take longer than 90 days to issue a decision. Unfortunately, all the disability insurance company has to do is send you a letter in order to get their automatic extension. Having experienced ERISA counsel will help keep the insurer on track with required deadlines and put you in a position to promptly file a lawsuit to enforce your rights if a timely decision is not made.

If you lose your appeal and want to challenge the decision instead of just giving up, your only option to get the insurance company’s decision reversed is to file a lawsuit under ERISA. If you have not already contacted an ERISA lawyer, then you should do so immediately before losing your chance to collect disability benefits. Some deadlines for lawsuits may be as short as 60 days, so act immediately after getting a denial.

Filing a Lawsuit

Since ERISA is a federal law, your lawyer will file your ERISA lawsuit in federal court. It is important to know that ERISA disability claimants are not allowed to seek bad faith damages or pain and suffering. The law only allows you to claim the disability benefits that were owed, attorney fees, and costs when you have employer-sponsored insurance benefits covered by ERISA.

When filing a lawsuit, the federal court will only review the evidence submitted by you or your attorney during the initial claim and the pre-lawsuit appeal. These cases are almost always decided on written motions and briefs, with the federal judge reviewing your claim file without a trial. In an ERISA case, you and your doctors will never be allowed to testify in court, so getting all of the necessary information and expert opinions into the claim file during the initial claim and appeal is a must. This further explains why it is crucial to have an experienced ERISA attorney on your side throughout each phase of your disability insurance appeal.

Your ERISA lawyer will have your best interests in mind when representing you during the disability appeals and lawsuit process. Without an attorney, you may be unable to collect disability benefits that you need and deserve.

Nationwide Representation for ERISA Claims

At Tucker Law Group, our nationally recognized law firm handles ERISA disability claims for disabled individuals throughout the United States. From Florida to Alaska, we protect our clients’ rights and aggressively fight for the benefits they need.

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Do you need short term or long term disability insurance benefits? Our law firm can step in to help at any stage of the ERISA claim process.

Contact Our ERISA Lawyers Today for a Free Consultation

If you have questions about ERISA law, disability insurance law or obtaining benefits, then it is important to speak to an experienced ERISA attorney today. Your attorney will be able to help you every step of the way, from filing the initial claim to filing a lawsuit.

At Tucker Law Group, our ERISA attorneys know how to obtain disability insurance benefits for our clients. We look forward to helping you receive the benefits you deserve. Contact our ERISA law firm for help today at (866) 233-5044 or schedule a free initial consultation. Our experienced attorneys handle ERISA insurance cases nationwide.

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