Frequently Asked Questions

If you work for a private employer, you probably are entitled to appeal your denial under the federal law called ERISA (that’s short for the Employee Retirement Income Security Act of 1974).

Federal regulations require your benefits administrator to provide an opportunity to appeal denial of your claim. Appealing a denial administratively is also usually a requirement before you can file a benefits lawsuit in federal court.

Even if your claim doesn’t fall under ERISA you likely have appeal rights and can challege a denial in court.

Claims are rejected for many reasons and early treatment records often don’t document the extent of an impairment. Updated records and provider opinions can make a big difference. The opinions and evaluations of experts and your supporting statements or statements from individuals who know you can also be important.

Appealing a denial on time and with your best evidence is crucial to enforcing your rights. An appeal is usually required before you can file a lawsuit.

In some cases, benefits plans permit a second appeal and we can help strengthen your claim before considering a lawsuit.

If that isn’t an option, we can evaluate whether your claim is suitable for filing a lawsuit to recover your benefits in federal court.

Private disability insurance lawsuits are heard in federal court. A judge will generally review the “record” (the claim administrator’s file, including all the evidence you submitted) and determine if you are eligible for benefits.

Federal court review is usually a “de novo” review, meaning the judge determines your eligibility for benefits independently without giving any weight to the administrator’s decision against you. Sometimes your benefits plan is entitled to an “abuse of discretion” review that does give the previous decision weight. In either case, you and your benefit plan each submit briefs explaining your positions on the basis of the evidence in the record and the court will make a decision.

Although a lawsuit may result in a judicial decision, you can also choose to settle with your insurer if you can come to an agreement.

After receiving a new claim, federal regulations require benefit plans to decide the claim or request additional information within 45 days. Initial claims usually take between 45 and 120 days to get a decision, depending on how quickly you respond to any requests for information.

If an administrative appeal is needed, it can take 45-120 days after the appeal is submitted to get a decision, again depending on whether new information is requested. In a complex case, the administrative claim and appeal process could take up to 6 months. If the claims administrator takes too long you can sue to move your claim to judicial review promptly.

If you are denied by your benefit plan, you can file a lawsuit in federal district court. It usually takes 3 to 6 months after filing for early issues to be dealt with and to explore settlement. If a judicial decision is needed, it usually comes within a year after the case is submitted. Unfortunately, decisions can sometimes take longer.

Appeals of a federal district court’s benefits decisions are uncommon, but if you or your claim administrator appeal a judicial decision it may take up to two more years to resolve.