We have talked about the model employee benefits attorney and the model client, and now we are going to talk about the model case, but one particular kind of case – the long-term disability case. Watch this video for traits of the model long-term disability case.
Know the Rules
1. The Notice of Claim
First, we are going to talk about the initial claim process of a long-term disability case, and that starts with the policy.
If your client suffers an accident or an illness, one of the first things to do (after they get medical care and treatment of course) is to look at their policy, so you can follow the rules of the policy.
The policy will usually include a Notice of Claim provision, which requires the claimant to give notice that they have a claim to the insurance company. If the claimant does not give the insurance company notice and too much time passes, that can be harmful or fatal to the claim. The model long-term disability case requires you to look at the policy to make sure you give proper notice to the insurance company at the address that is listed in the policy.
2. Proof of Loss
Second, you will also have to give proof of loss to the insurance company or plan administrator within a certain amount of time.
Proof must go to the address listed in the policy or to the address on the forms that may have been provided at this point. Once you have given that proof of loss and the notice of claim has been furnished, there are 45 days for the insurance company or administrator to make a decision. So, if a claim is filed on June 1st, then by July 15th there should be a claim decision. The requirements of a full and fair review give insurance companies 45 days to make that decision.
3. An Extension of Time
There can be circumstances beyond the control of the insurance company or plan administrator where more time is needed.
For example, there may be a request for medical records from the claimant's doctor's office, and the doctor is on vacation and not available to approve sending the records, causing the response to the request may be delayed. That is just one possible example. Basically, if the insurance company has such special circumstances beyond their control, they can take another 30 days as long as they give notice of that within the time period required.
Usually, that notice of those circumstances must be made within that 45-day time period. That means the claimant has to wait 75 days for the long-term disability benefit; however, that is legal and within the ERISA claim procedure regulation. Sometimes additional special circumstances can arise. Before that lapse of the 30-day extension occurs, sometime before day 75, they can then add another 30 days up to a total now of 105 days. That means that from the time the claimant gives them proof that they were disabled,105 days can pass until they finally make a decision.
There can be some other wrinkles and considerations including if the insurance company sends the claimant a letter or calls and asks for information. If this occurs, the claimant has to get the information to them right away because the insurance company will not count those days where they are waiting on information against their 105-day total. For example, if on June 5th, they ask the claimant for their W-2, and they do not send it to them until July 5th, that 30-day time frame does not count against the insurance company. The clock was stopped while they were waiting on the claimant to give them information. With a long-term disability claim, it is in the claimant's best interest to furnish the information required to the insurance company right away.
In the model long-term disability case, a claim decision is made within the initial claims process. If it is not, then the claim can be considered “deemed exhausted.” That means the claimant can now take their case to court, and they do not have to go through the claim procedures anymore because the insurance company has not followed them. The ERISA claims process is complex. Having an experienced ERISA long-term disability attorney on the case is essential to ensuring your client's case is resolved as quickly as possible. Let us know if we can help.