If an employee has an issue with an employer’s disability benefits plan, he or she must file a disability claim internally before pursuing a case in a court of law.

The Employee retirement Income Security Act (ERISA) is the law that regulates disability and health benefits plans offered by private employers.

What Materials Should Be Reviewed Before Pursuing a Disability Claim?

Employees filing for disability benefits must be familiar with several sources of information. For example, the disability plan’s summary description (SPD) may contain the following:

  • An employee’s rights under ERISA
  • The responsibilities of employers with respect to disability claims and benefits
  • An outline of how your employment-based disability plan works
  • A description of your plan benefits and qualifications
  • A description of how and when benefits will be paid to qualifying employees

Where to Get More Information for Your Disability Claim?

In addition to the summary plan description (SPD), more information may be found in a special booklet supplied by your employer.

If employee-employer collective bargaining has occurred, you may need to read the appropriate sections of the collective bargaining agreement. In any case, having these documents handy may help you to have an informed discussion with an attorney later:

  • A summary plan description
  • A claims procedure booklet
  • A collective bargaining agreement

After the Filing: How Do Disability Claims Get Decided?

Depending on the nature of the health concern, your claim may end up in a category that you had not anticipated. Claims for serious health issues may not be designated as "disability" claims. The review of your claim will depend on its category.

However, if you are filing a true disability claim, the following timeframe and guidelines apply:

  • A decision must be made within the 45 days from receipt of the claim
  • If more time is needed, the plan has to notify you
  • A notification must explain why more time is needed
  • An extension may be granted for up to 30 days
  • If more information is requested, you may have to provide it within 45 days
  • The plan again may have up to 30 days from the receipt of your new information
  • After the first 30 day extension, another extension may be made if notice is sent
  • Any additional extensions require the applicant’s consent

Finally, if your disability claim gets denied, you must be notified. The notice must contain an explanation as to why your disability claim has been denied as well as how to appeal this denial.

After the Denial of a Disability Claim: How to Prepare for the Appeal Process

To prepare for the appeal process, use some of the materials you already have but don’t forget that you can also request more relevant materials. For example, you may request pertinent records from your plan free of charge. You can also request the names of medical professionals involved in the claim’s denial.

The usual timeframe for appeal is within the 180 days of denial. However, your plan booklet or SPD may provide for a different timeframe

The timeline is similar to that in the initial filing of the claim. The following may take place in the appeal process:

  • 45 day time window with a 45 day extension is given
  • A different timeframes may be used for collective bargaining agreements
  • An applicant must receive a written notification of the decision

Seeking Judicial Review

After an appeal has been denied by the plan, an employee may seek a court judgment on the issue of his disability benefits. However, it is important to note that an employee may be able to go to the court without going through the appeal process. This is true if an employee believes that the disability or health plan does not follow ERISA rules and does not have a fair process for addressing the claims of employees.

Do I Need Help from an Attorney?

If you are an employee seeking to file a disability claim, appeal the denial of your disability claim, or seek judicial review for your claim, you may need help from an experienced employment benefits attorney.

As noted earlier, if your plan doesn’t comply with ERISA and lacks adequate procedures for disability benefits claims, it may not be necessary to go through all the internal appeal processes. Therefore, an attorney can help you get your claimed reviewed by the court much sooner than you or your plan may suspect.