Appealing the Denial of an ERISA Disability Claim
If a disability claim is governed by ERISA, a claimant has a right to appeal an adverse decision made by the insurance carrier or plan. Likewise, disability claims not governed by ERISA usually include an opportunity to appeal an adverse decision.
The right to appeal is one of the most important aspects of an ERISA disability claim. Courts are generally limited to considering the contents of the claims file created during the claim and appeal. This means that if the initial claim is denied, the claimant has another chance to strengthen and fortify the claims file before filing a lawsuit.
If the initial claim is denied, the insurance carrier or plan administrator is supposed to tell the claimant why. The carrier or plan is then supposed to provide a reasonable time to appeal the denial. For disability claims submitted after January 1, 2002, the federal regulations provide an appeal period of 180 days.
During the appeal, the claimant should make efforts to address the reasons for the claim denial. If, for example, the insurance carrier says that there is no medical proof to support the claim, then the claimant may want to provide medical reports and records to substantiate the disability and impairment. The claimant might also want to submit medical literature, textbooks, illustrations, and other information appropriate to the situation.
As part of the appeal, the claimant may also want to consider submitting statements from the claimant, as well as her family members, friends, and co-workers, to address the claimant's impaired condition and its affect on her life. Other helpful materials may include photographs, videotapes, written job descriptions, expert vocational reports, favorable rulings from the Social Security Administration, and other things.