If your claim for long-term disability (LTD) or short-term disability (STD) benefits has been denied, the ERISA disability appeal may be your best opportunity to secure the benefits you deserve. Under the Employee Retirement Income Security Act of 1974, commonly known as ERISA, the administrative appeal process is not just a procedural formality; it is the foundation upon which your entire claim will rest if your case proceeds to federal court.
This blog post explains why a comprehensive ERISA disability appeal is essential to recovering your disability insurance benefits, the critical deadlines you must follow, and how working with experienced ERISA disability attorneys can make all the difference in your case.
What Is ERISA and How Does It Affect Your Disability Claim?
ERISA is a federal law that governs most employer-sponsored benefit plans, including disability insurance plans that provide LTD and STD benefits. If you receive your disability coverage through your employer, your claim is likely governed by ERISA, which means specific federal rules and procedures apply.
One of the most significant aspects of ERISA is its requirement that plans provide participants with a “full and fair review” of their claims. This requirement is codified in Section 503 of ERISA, 29 U.S.C. § 1133, and is implemented through detailed regulations found at 29 C.F.R. § 2560.503-1. These regulations establish the minimum standards for how claims must be processed, what information must be provided when a claim is denied, and the procedures for appealing an adverse decision.
If your disability benefits are wrongfully denied after you have exhausted the administrative appeal process, you may bring a lawsuit under ERISA Section 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B), to recover benefits due to you under the terms of your plan. This provision allows plan participants and beneficiaries to sue in federal court to recover benefits owed, enforce their rights under the plan, or clarify their rights to future benefits.
Understanding the Deadlines for Your Disability Appeal
Time is of the essence when your ERISA disability claim has been denied. The regulations provide specific deadlines that you must follow, and missing these deadlines can result in waiving your right to appeal entirely.
Initial Claim Decision Timelines
For disability claims, the insurance company or plan administrator has 45 days to make an initial decision on your claim after it is received. This period may be extended by up to two additional 30-day periods if matters beyond the plan’s control prevent a timely decision, but only if the plan notifies you of the extension before the deadline expires. During any extension, the plan must explain the reasons for the delay, the unresolved issues, and any additional information needed to resolve the claim. ERISA disability insurers often violate this process.
The Critical 180-Day Appeal Window
Once you receive written notice that your disability claim has been denied, you have no less than 180 days to file your appeal. This deadline is mandatory under the ERISA regulations, and plan administrators cannot shorten this timeframe for disability claims. They can always agree to extend it, but often will be reluctant to do so because they are biased due to their conflict of interest as the adjudicator and payor of claims.
It is critically important that you calendar this deadline immediately upon receiving your denial letter. The 180-day period begins from the date you receive the adverse benefit determination, not the date the letter was written. Best practice dictates that you should submit your appeal using a trackable delivery method so you can prove when the plan received your appeal materials.
Appeal Decision Timeline
After you submit your appeal, the plan administrator must issue a decision within 45 days. The plan may extend this period by an additional 45 days if special circumstances require more time, but only if you are notified before the initial 45-day period expires. If the plan fails to issue a timely decision, your claim may be deemed denied, allowing you to proceed directly to federal court. Again, insurers often violate these rules. For example, Reliance Standard Life Insurance Company is a frequent offender in this regard.
Why Building a Comprehensive Appeal Record Is Essential
The administrative appeal is your opportunity to build the evidentiary record that will follow your case into court. This point cannot be overstated: in most ERISA cases, the court’s review is limited to the evidence that was part of the record created during the claims process. Although your attorney may attempt to obtain discovery in litigation, discovery may be significantly limited, and courts generally will not consider new evidence that was not submitted during the appeal.
Essential Components of a Strong Appeal
A comprehensive disability appeal often will include the following elements:
- Complete medical records: All treatment notes, diagnostic test results, imaging studies, and laboratory findings that document your condition;
- Treating physician opinions: Detailed statements from your doctors explaining your functional limitations, restrictions, and inability to perform work duties;
- Vocational evidence: Job descriptions, work demands analyses, and vocational assessments that demonstrate you cannot perform your occupation or any occupation, depending on the plan’s definition of disability;
- Social Security disability determination: If you have applied for and received Social Security disability benefits, that determination should be included;
- Personal statements: Your own detailed account of how your disability affects your daily activities and ability to work;
- Third-party statements: Declarations from family members, friends, and former colleagues who can describe how your condition has changed your capabilities;
- Functional capacity evaluations: Professional assessments of your physical or mental abilities to perform work tasks; and
- Medical literature: Peer-reviewed articles and studies that support your claim.
Responding to New Evidence and Rationales
The ERISA regulations were amended effective April 1, 2018, to provide important additional protections for disability claimants. Under these enhanced regulations, if the plan develops or relies on any new evidence or rationale during the appeal process, it must provide you with that information free of charge and give you a reasonable opportunity to respond before issuing a final decision.
This means you have the right to know what the plan is considering and to address any concerns before your appeal is decided. If the plan fails to provide this information, it may have failed to provide you with a full and fair review, which can have significant consequences in subsequent litigation.
Consequences of an Inadequate Appeal
Failing to submit a comprehensive appeal can have devastating consequences for your case. If your appeal lacks sufficient evidence to support your disability claim, the plan administrator will likely uphold the denial. More importantly, if your case proceeds to federal court, you will likely be stuck with an incomplete record.
Under the deferential “abuse of discretion” standard of review that applies when plans have discretionary authority, courts generally limit their review to whether the administrator’s decision was reasonable based on the evidence in the administrative record. Without strong medical, vocational, and personal evidence in your appeal, you will have given the court little basis to overturn the denial.
Conversely, if the plan fails to follow the claims regulations—such as failing to provide required notices, missing deadlines, or not considering your evidence—courts might apply a less deferential “de novo” standard of review, which can significantly improve your chances of success.
How The Garner Firm Can Help
Navigating the ERISA disability appeal process is complex, and the stakes are high. Insurance companies have teams of adjusters, medical reviewers, and attorneys working to protect their bottom line. You deserve experienced legal advocates on your side who understand the intricate web of ERISA regulations and know how to build a winning appeal.
At The Garner Firm, we focus on ERISA and employment law, giving us deep expertise in the complex procedures that govern disability claims. Our attorneys have handled ERISA lawsuits in state and federal courts nationwide, including claims for benefits under Section 502(a)(1)(B) of ERISA. We have successfully helped countless clients navigate the challenging appeals process, recover wrongfully denied benefits, and secure the financial support they need.
Firm founder Adam H. Garner has two decades of experience as an ERISA, insurance, and employment attorney and has built a reputation as a dedicated advocate for employee benefit plan participants. As a former administrator of multi-million and billion-dollar multiemployer benefit plans, Mr. Garner has firsthand insight into the policies, procedures, and fiduciary obligations that govern disability programs. He serves as Senior Editor of the treatise Employee Benefits Law, published by the American Bar Association in conjunction with Bloomberg.
What Sets Us Apart
- ERISA focus: We concentrate on ERISA and employment law cases
- Proven results: We have a successful track record of overturning benefit denials
- Comprehensive approach: We handle every aspect of your claim from initial denial through federal court litigation
- No upfront costs: We work on a contingency basis—you pay nothing unless we recover benefits
- Personalized attention: You will have direct access to experienced attorneys, not just paralegals or other support personnel
Take Action Before It Is Too Late
If your disability claim has been denied, time is not on your side. The 180-day appeal deadline runs whether or not you are represented by counsel, and every day that passes is one less day to gather evidence and build your case.
Do not let the insurance company’s denial be the final word. Contact The Garner Firm today at (267) 805-6557 to schedule a consultation. We will review your denial letter, evaluate the strength of your appeal, and explain your options for pursuing the long-term disability or short-term disability benefits you are owed.
Your financial security and peace of mind are too important to leave to chance. Let us fight for your rights.