A denial of long-term disability benefits is not necessarily the end of an ERISA claim. Instead, it usually begins one of its most important stages: the administrative appeal.
Two issues deserve immediate attention. First, there is a deadline for appealing. Second, the appeal is an opportunity to develop the evidence supporting your disability claim. Simply telling the insurer that its decision was wrong is rarely enough.
For someone who has spent years or decades in a career and can no longer perform that work because of a serious, chronic, or progressive condition, the appeal should address why the claim was denied and document why the claimant satisfies the disability policy.
Key Takeaways
- ERISA disability plans generally must provide at least 180 days to appeal an adverse benefit determination.
- Your denial notice and plan documents should be reviewed promptly to determine the procedure that applies to your claim.
- The appeal can include additional medical, vocational, and occupational evidence.
- Evidence developed during the administrative process can become critically important if the dispute later reaches federal court.
- A final administrative denial does not necessarily end the claim. Judicial review may still be available under the law.
What Should You Know Before Filing an ERISA Disability Appeal?
If an employer-sponsored long-term disability claim governed by ERISA is denied, federal rules generally provide at least 180 days after receiving the adverse benefit determination to appeal. The appeal is also a critical opportunity to add medical, vocational, and other evidence to the administrative record that may later be important in federal court.
How Long Do You Have to File an ERISA Disability Appeal?
Federal claims-procedure regulations require Employee Retirement Income Security Act disability plans to provide claimants at least 180 days following receipt of an adverse benefit determination to appeal. The U.S. Department of Labor advises claimants to check their Summary Plan Description and claims procedure because a particular plan may provide a longer period.
That does not mean you should independently count 180 days and assume you have identified your deadline. Your denial notice and governing plan documents need to be reviewed to determine the applicable procedure.
Missing a required administrative appeal deadline can have serious consequences. Federal law generally requires claimants to exhaust required administrative remedies before pursuing a benefit dispute in federal court, although exceptions can apply.
Promptly addressing the denial also leaves more time to obtain the claim file, determine why benefits were denied, and develop evidence for the appeal.
What Is the Administrative Record in a Disability Claim?
The administrative record generally consists of materials developed and considered during the benefit claim and administrative review process. It can include medical records, claim forms, correspondence, treating provider opinions, insurer medical reviews, vocational assessments, occupational information, surveillance, and other evidence related to the claim.
If the insurer upholds its denial and the dispute proceeds to federal court, this record can become central to judicial review. Depending on the applicable standard and circumstances, opportunities to introduce new evidence later can be limited.
That makes an administrative appeal more than a request that the insurer reconsider its decision. It is an important opportunity to identify weaknesses in the insurer's reasoning and build the evidentiary record supporting the claim.
What Evidence Should You Submit With an Appeal?
There is no standard appeal package appropriate for every LTD claim. The evidence should respond directly to the policy language and the reasons given for denying benefits.
Federal regulations allow claimants to submit written comments, documents, records, and other information relating to the claim. Claimants can also generally request relevant claim materials without charge.
Depending on the dispute, important evidence may include:
- Treating-provider support: Medical records and opinions explaining functional limitations, not merely diagnoses.
- Occupational or vocational evidence: Information connecting medical restrictions to the duties of the claimant's occupation or addressing other work the insurer says the claimant can perform.
- Responses to insurer reviews: Evidence addressing an independent medical examination, file review, surveillance, or other information the insurer used to deny benefits.
Medical evidence is particularly useful when it explains what someone can and cannot do throughout a workday. For a person with an established career, the analysis should connect those restrictions to actual occupational demands. Vocational evidence can become especially important when an LTD policy changes from an own-occupation definition of disability to an any-occupation standard.
If an insurer relied on an IME or medical consultant, an appeal should address significant conflicting opinions rather than merely resubmit the same records available when the initial decision was made. Our LTD IMEs & Insurer Investigations resource explains those reviews in greater detail.
Why Does the Administrative Record Matter Under Arbitrary-and-Capricious Review?
The record can become particularly important when the plan gives the decision-maker discretionary authority and a federal court applies an arbitrary-and-capricious standard of review.
Under this deferential standard, the court does not simply decide the disability claim from the beginning. The Seventh Circuit has explained that review considers whether the administrator gave specific reasons for its determination, afforded the claimant a full and fair review, and provided reasoning supporting its decision.
The practical lesson is important: do not deliberately save useful evidence or arguments for a future lawsuit when they can and should be developed during the administrative appeal.
Our guide to Understanding the Arbitrary and Capricious Standard of Review examines the federal court’s standard of review in greater detail.
Does Requesting Records Pause the 180-Day Appeal Period?
Do not assume that requesting the claim file, talking with the insurer, undergoing additional treatment, or gathering medical evidence automatically pauses the appeal deadline. ERISA regulations contain specific timing requirements, and the plan's procedures can also affect how a particular claim proceeds.
Because missing a required appeal can jeopardize the claim, someone who receives an LTD denial should have the denial notice and plan documents reviewed promptly rather than relying on a deadline calculated from general information online.
What Happens After You File the Appeal?
The plan must provide a full and fair review of the adverse benefit determination.
For disability claims, federal regulations generally require a decision on appeal within 45 days, with a possible extension under specified circumstances. Different timing provisions can apply to certain plans.
The review must consider information submitted by the claimant relating to the claim, including information that was not considered during the initial decision. If the appeal succeeds, benefits may be approved or reinstated. If the plan again denies benefits, the written decision should explain the basis for the determination and provide information concerning judicial review.
Can You File a Lawsuit After an Appeal Is Denied?
A denied administrative appeal does not necessarily end an LTD claim. After completing the required administrative remedies, a claimant may file an action in federal court seeking benefits due under the plan. The litigation can involve the policy language, applicable standard of review, administrative record, procedural compliance, and the basis for the plan administrator's decision.
This is why preparing for potential litigation begins before a lawsuit is filed. Evidence developed during the administrative appeal can affect what happens if the dispute reaches court. Our Long-Term Disability Denial & Appeals resource explains the broader process for challenging a denied LTD claim.
Frequently Asked Questions About ERISA Disability Appeals
Do I always have exactly 180 days to appeal an LTD denial?
No. Federal regulations generally require disability plans to provide at least 180 days after receipt of an adverse benefit determination. A plan may provide additional time. The applicable documents and circumstances should be reviewed rather than relying on a deadline derived from general online information.
Can I submit new medical evidence with an ERISA appeal?
Yes. Federal claims procedures allow claimants to submit documents, records, comments, and other information relating to the claim. The appeal is an important opportunity to provide evidence addressing the reasons for the denial.
Can I get a copy of the claim file?
Legal procedures generally give claimants the right, upon request and without charge, to reasonable access to and copies of documents and information relevant to the claim. Reviewing those materials can help identify the evidence and reasoning behind the denial.
What if I miss the appeal deadline?
Missing a required administrative appeal can jeopardize the ability to pursue benefits further because the law generally requires exhaustion of the plan's administrative remedies. Exceptions and procedural issues can arise, so someone concerned about a missed deadline should seek legal advice rather than assuming the claim is over.
Talk to an ERISA Disability Attorney at Hawks Quindel, S.C.
An appeal is not simply paperwork standing between a denial and a lawsuit. It is an important opportunity to challenge the insurer's reasoning, develop medical and vocational evidence, and create a record supporting your claim for long-term disability benefits.
The attorneys at Hawks Quindel, S.C. represent workers and individuals in ERISA and long-term disability disputes. We can review your denial and plan documents, analyze claim materials, identify evidence that may need to be developed, and prepare an administrative appeal when we can assist.
Contact Hawks Quindel, S.C. to begin the intake process and learn whether your matter qualifies for a free case screening. Call our Madison office at 608-257-0040 or our Milwaukee office at 414-271-8650, or fill out our confidential contact form.