The Employee Retirement Income Security Act of 1974 (ERISA) protects the interests of participants and their beneficiaries who depend on benefits from private employee benefit plans rather than privately procured insurance. An employee welfare benefit plan is a plan, fund or program that provides medical, surgical, hospital, sickness, accident, disability, death, severance, unemployment, vacation, apprenticeship, day care center, scholarship funds and pre-paid legal benefits. The claiming procedure can be difficult, with strict deadlines and rigorous documentation. The exact requirements for seeking benefits are contained within the insurance contract and vary from policy to policy.
Most policies require that the employee file a claim for benefits with the person designated by the plan to receive such claims. The plan might also require immediate notification when an employee enters the hospital or sees a doctor. Other plans require that the employee actually pay the medical bill and seek reimbursement. A frustrating requirement of some policies is a detailed substantiation by a physician explaining an inability to perform each necessary work function. This documentation can be difficult to satisfy without legal assistance.
The disability insurance carrier must respond to the claim within 90 days, or 180 days if an extension is granted. If there is no response, the claimant can infer that the claim has been rejected. ERISA requires that the plan explain the reasons for denial and include an explanation of the process for full review and appeal. Most plans require an appeal to be filed within 60 days, unless the insurance carrier offers a longer period. Any action on the appeal must be made by the carrier within 120 days of the appeal filing.
Failure to strictly comply with ERISA and insurance policy contract terms can shutout an otherwise qualified claimant. Disability claimants should consult with an experienced ERISA disability insurance attorney to protect their benefits and rights. An experienced attorney can negotiate a lump sum claim settlement, litigate inappropriate denials of claims and even pursue insurance bad faith lawsuits.