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The “Good” of ERISA: The Claim Procedure or “The Claim Process”

Posted by David P. Martin | Sep 16, 2019 | 0 Comments

There is a lot of unfairness for claimants and participants with ERISA. ERISA may apply to long-term disability, short-term disability, life insurance, pension and retirement benefits.

There are a lot of bad things about ERISA, but there are also good things about ERISA that if used to your advantage can drastically and positively impact your claim.

In the last month, we have talked about how your ability to obtain your claim record and plan documents as well as penalties and attorney's fees were four good things about ERISA. The fifth good thing about ERISA is the claim procedure or “the claim process.”

Those disclosure obligations in obtaining the claim record and plan documents are important, and that is part of the claim procedure. The way the claim procedure works is there are time limits for the insurance company to make a decision. And then, you have time limits to respond to that decision.

For example, with a long term disability case, they're supposed to make the initial claim decision within a maximum of 105 days, even with extensions. They're supposed to make it in a shorter time, but if there are circumstances beyond their control, it can be longer and up to 105 days. Then, the claimant has a minimum of at least 180 days (It could be longer, but the claim procedure regulation says the least amount of time you should be allowed is 180 days) to appeal and challenge that determination.

During that time, you want to immediately obtain the claim record and all of the plan documents to assemble and articulate your evidence back to the insurance company. That's where a skilled ERISA practitioner comes in handy. That's the time when you want to make the claim record very strong, so that you show that there's no reasonable basis whatsoever to the insurance company's decision.

This claim process, which is supposed to involve a meaningful exchange of information and meaningful disclosure, is very good for claimants because it allows the possibility of prevailing with your claim because you know exactly why it was denied once you receive all those documents and information. On the other hand, it also allows you to make your claim record very strong, so when you take the insurance company into litigation, you don't have a loser of a case.

You want to make your claim record very strong, so you have a winning case going into litigation. If you go into litigation with a weak case, you will lose. Obtaining an attorney during that claim process is important, but the claims process itself is a big advantage.

If the decision maker, whether it's an insurance company, a plan administrator, or claims administrator, is not fair during the claim process and they violate the claim procedure regulation, then the Department of Labor says the claim is deemed exhausted. That means you don't have to continue to go through that claim process anymore because there's so much unfairness that there will be no full and fair review, and therefore, you have the right to go into litigation at that point. That can often happen.

If you need assistance after your long-term disability claim has been denied, contact an experienced ERISA disability lawyer or long-term disability lawyer today at 800-284-9309.

About the Author

David P. Martin

Senior & Managing Attorney


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