Understanding the ERISA Claims and Appeals Process

If you are unable to work due to a disability, ERISA regulations will play a substantial role in determining how you obtain benefits. Understanding ERISA and how it applies to your long-term disability claim can help you as you work through the process. An experienced New Jersey disability lawyer can counsel you on the claim requirements based on your specific policy.

ERISA and the Interplay with the Disability Claims Process

A specific section of ERISA — 29 CFR §2560.503-1 —regulates claims procedures for benefits plans that are covered by the law. Plans providing disability benefits have an obligation to establish and maintain reasonable claims procedures. This includes:

• All ERISA claims procedures and all applicable time frames are included in the summary plan description;
• The appeals procedures do not include any provision that would inhibit a beneficiary from filing a claim (such as requiring a fee to file a claim);
• The claims procedures do not prevent an authorized representative from acting on behalf of a claimant; and
• The claims procedures have administrative processes and safeguards to ensure that determinations regarding benefits are made in accordance with the plan documents and that plan provisions have been applied consistently.

In addition to the above requirements, all ERISA disability plan claim procedures must:

• Provide an “explanation of the basis for disagreeing with or not following” the “views” of treating and consulting medical and vocational specialists for adverse benefit and appeal determinations;
• Provide “Either the specific internal rules, guidelines, protocols, standards or other similar criteria of the plan relied upon in making the adverse determination or, alternatively, a statement that such rules, guidelines, protocols, standards or other similar criteria of the plan do not exist” for adverse benefit and appeal determinations;
• Provide “explanation of the basis for disagreeing with or not following” “SSDI determination” for adverse benefit and appeal determinations;
• Disclose to the claimant “any new or additional evidence considered, relied upon, or generated” by the plan “in connection with the claim”, as well as any “new or additional rationale.” These materials must be disclosed “as soon as possible and sufficiently in advance of the date on which the notice of adverse benefit determination on review is required … to give the claimant a reasonable opportunity to respond prior to that date” before making an adverse appeal determination;
• “Describe any applicable contractual limitations period that applies to the claimant’s right to bring such an action, including the calendar date on which the contractual limitations period expires for the claim” in appeal decision letters.

The ERISA claims procedure can be confusing, particularly if you are already dealing with an illness or injury that requires you to devote your time and attention to your recovery. While the plan administrators are required to establish reasonable claims procedures and follow certain rules, you must also comply with the process set forth in the plan documents — or risk losing your ability to access benefits. If you are struggling with getting this done, a New Jersey disability attorney can work with you to put together a claim and handle any appeals, if necessary.