Receiving a denial of disability benefits under an employer-sponsored plan can create uncertainty about what to do next. If your disability benefits are governed by the Employee Retirement Income Security Act (ERISA), the denial notice may be only one stage in the claim process.
ERISA plans generally have specific procedures for reviewing denied claims. Understanding the reasons for the denial, applicable deadlines, and available appeal options can help you determine your next steps.
Why Are ERISA Disability Claims Denied?
Disability insurers and plan administrators evaluate claims according to the terms of the applicable benefit plan. A claim may be denied for medical, occupational, procedural, or policy-related reasons.
Common issues that may contribute to a denial include:
- Insufficient medical documentation
- Questions about the severity of a medical condition
- Lack of evidence showing functional limitations
- Disagreement with a treating physician’s assessment
- Questions about the claimant’s ability to perform occupational duties
- Missing forms or requested documentation
- Policy exclusions or limitations
- Failure to satisfy the plan’s definition of disability
- Changes in the applicable definition of disability
- Missed filing or documentation deadlines
Every claim is different, so the specific reasons provided in the denial notice should be carefully reviewed.
Understanding Your Denial Letter
A denial letter can contain important information about why benefits were denied or terminated. It may discuss the medical evidence considered, applicable plan provisions, findings from medical or vocational reviewers, and procedures for requesting an appeal.
Claimants should keep a copy of the denial letter along with other correspondence, medical documentation, plan documents, and records related to the disability claim.
Appealing an ERISA Claim Denial
ERISA disability plans generally provide an administrative process for challenging an adverse benefit determination. An appeal is an opportunity to address the insurer’s stated reasons for denial and provide additional information supporting the claim.
Depending on the circumstances, an appeal may include:
- Updated medical records
- Statements from treating physicians
- Additional diagnostic or clinical evidence
- Documentation of physical or cognitive limitations
- Occupational or vocational information
- Evidence addressing specific findings in the denial
- Other documentation relevant to the plan’s disability requirements
Simply resubmitting the same information may not address the issues identified by the insurer. A thorough appeal generally focuses on the reasons given for the adverse decision.
Pay Attention to Appeal Deadlines
ERISA claims are subject to procedural requirements and deadlines. The denial notice and applicable plan documents should explain how and when an administrative appeal may be submitted.
Missing an important deadline could affect the ability to continue challenging a denial. Claimants should therefore review notices promptly and keep records of important dates and submissions.
The Administrative Record Matters
The evidence developed during the claim and administrative appeal process can become important if the dispute later proceeds to litigation.
Depending on the circumstances, a court reviewing an ERISA benefits dispute may focus substantially on the administrative record created before litigation. This makes it important to consider whether relevant medical, occupational, and other supporting evidence has been included during the administrative process.
When Disability Benefits Are Terminated
ERISA disputes do not involve only initial claim denials. An insurer may approve benefits and later determine that the claimant no longer satisfies the plan’s requirements.
A termination may occur following a medical review, changes in medical documentation, surveillance or other evidence, or a change in the policy’s definition of disability. Claimants may have appeal rights when previously approved benefits are terminated.
Get Help With a Denied ERISA Disability Claim
Challenging an ERISA disability denial can involve detailed plan language, medical evidence, occupational information, administrative procedures, and strict deadlines.
Atlanta ERISA Disability Lawyer is an informational and lead-generation resource that helps individuals seeking legal assistance connect with independent attorneys who handle ERISA disability claims and appeals.
If your disability claim has been denied or your existing benefits have been terminated, complete our contact form to request information about potential assistance with your claim.
