ERISA Disability Benefit Terminations

Receiving disability benefits does not always mean those benefits will continue indefinitely. Under an employer-sponsored disability plan governed by the Employee Retirement Income Security Act (ERISA), an insurance company or plan administrator may periodically review a claim to determine whether the claimant continues to satisfy the plan’s requirements.

If long-term or short-term disability benefits are terminated, understanding the reason for the decision and the available appeal process can be an important next step.

Why Can Disability Benefits Be Terminated?

Disability insurers may periodically request updated information about a claimant’s medical condition, treatment, functional limitations, or ability to work. Based on this information, an insurer or plan administrator may determine that continued benefits are no longer payable under the terms of the plan.

Reasons cited in a benefit termination may include:

  • A determination that medical evidence no longer supports disability
  • Changes or perceived improvement in the claimant’s condition
  • Insufficient updated medical documentation
  • Findings from an independent medical review or examination
  • Questions about physical or cognitive functional limitations
  • Changes in the plan’s definition of disability
  • A determination that the claimant can perform another occupation
  • Policy exclusions or limitations
  • Surveillance or other information considered by the insurer
  • Failure to provide requested documentation

The specific reason for terminating benefits should generally be explained in the insurer’s written decision.

Changes in the Definition of Disability

Some long-term disability plans use different definitions of disability at different stages of a claim. For example, a plan may initially evaluate whether a claimant can perform the duties of their regular or “own” occupation and later consider whether the claimant can perform another or “any” occupation as defined by the plan.

When the applicable definition changes, the insurer may conduct a new medical and vocational review. The exact language of the disability plan is important when determining what requirements apply.

Review the Termination Letter Carefully

A benefit termination letter may contain important information about the insurer’s reasoning, evidence considered, applicable plan provisions, and procedures for challenging the decision.

Claimants should carefully review the letter and retain copies of relevant claim documents, medical records, correspondence, and other materials. It can also be helpful to identify the evidence the insurer relied upon when deciding to discontinue benefits.

Appealing a Termination of Disability Benefits

A termination of previously approved benefits may be subject to an administrative appeal process. An appeal provides an opportunity to challenge the insurer’s conclusions and submit evidence addressing the reasons benefits were discontinued.

Depending on the circumstances, supporting information may include:

  • Updated medical records
  • Treating physician statements
  • Diagnostic or clinical evidence
  • Documentation of continuing restrictions and limitations
  • Occupational information
  • Vocational evidence
  • Information addressing medical or vocational reviews obtained by the insurer

A successful appeal cannot be guaranteed, and the evidence needed will depend on the individual claim and plan requirements.

Deadlines and the Administrative Record

ERISA disability appeals can involve important procedural deadlines. Claimants should review the termination notice and applicable plan documents promptly to determine when an appeal must be submitted.

The administrative record developed during the claim and appeal process may also become important if the dispute later proceeds to litigation. For this reason, claimants should carefully consider the information and supporting evidence included with an appeal.

What Happens If the Termination Is Upheld?

If the insurer or plan administrator maintains its decision after the required administrative review, additional legal options may be available. Depending on the circumstances, a claimant may be able to pursue a claim under ERISA in federal court.

ERISA litigation involves specialized procedural and legal issues, so the available options will depend on the plan, claim history, administrative record, and applicable law.

Get Help With Terminated Disability Benefits

The termination of disability benefits can create significant concerns, particularly when a claimant continues to experience medical limitations that interfere with the ability to work.

Atlanta ERISA Disability Lawyer provides general information and helps individuals seeking legal assistance connect with independent attorneys who handle ERISA disability benefit claims, terminations, appeals, and related disputes.

If your disability benefits have been terminated, complete our contact form to request information about potential assistance with reviewing your claim and available options.