If you suffer an injury or an illness that causes you to miss more than just a week or two of work, you may submit a short-term disability claim to help ease your financial burden. However, 45 days later, you may be surprised and disappointed to find a denial letter in your mail instead of one accepting your claim.
Filing an appeal is one option with which you have a legal right to respond to a claim rejection. In fact, many short-term disability applicants—whether they are subject to ERISA protections or not—hire a lawyer to file their appeal for them. Even if you have handled your short-term disability claim on your own up until now, you can obtain the services of a seasoned insurance attorney to help with appealing a denied short-term disability claim.
After submitting the required forms and proof of disability, a claimant applying for ERISA short-term disability benefits should receive a notification of approval or denial. This notification usually comes in the form of a letter, and it is very important that claimants read it carefully. If the claimant is denied coverage, the letter should state why. If it does not, the claimant or their attorney should contact the relevant agency to find out why.
Much like the initial application, appealing a denied short-term disability claim for a policy governed by ERISA can be intimidating and confusing. There are strict guidelines that must be met and information that must be included for an appeal to be valid. Not adhering to these rules almost always leads to a denied appeal.
Once the claimant has received notification that their claim was denied, they have 180 days to file an appeal, as per 29 C.F.R. § 2560.503-1 (h)(3)(i). If this deadline passes without an appeal being filed, the claimant may have no other way to appeal or pursue their claim any further.
When the insurance company receives the appeal for an ERISA-governed plan, they have 45 days to provide the claimant with a decision. However, under certain circumstances, the insurance carrier may request additional time to review the appeal. In such a case, they may have up to 45 additional days but are required to give an explanation to the claimant regarding why they need the extra time and when they will render a decision.
If the initial appeal is denied, some insurance plans may allow for the applicant to file a second appeal. An attorney who is familiar with ERISA short-term disability plans could examine the applicable laws and policy documents to determine if a second appeal should be granted. If so, they may be able to help with the process.
However, if the second appeal is also denied, there are other options for the applicant. With the help of their lawyer, they could file a suit in federal court to potentially get the claim accepted. This process is unlike civil court and is usually more successful with representation from professional legal counsel.
Appealing a denied short-term disability claim may be easier and potentially more successful with a qualified insurance lawyer on your side. Attorneys who are experienced in disability claims and ERISA regulations may be able to help you submit a thorough and accurate appeal, increasing your chances of receiving the disability benefits you need.
In addition, they may be able to obtain additional information from your physicians to help support your claim or to help the insurance company understand their responsibility to you and your need for short-term disability benefits. Call today to learn more about the services available to you and ensure you do not have to go through the appeals process alone.
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