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How long does the disability insurance company have to make a claim decision once the application for ERISA long term disability benefits is submitted?

The Department of Labor has drafted regulations which provide that a disability claim must be resolved, at the initial level, within 45 days of receipt of a complete application; a plan may, however, extend that decision-making period for an additional 30 days for reasons beyond the control of the plan.

If, after extending the time period for a first period of 30 days, the plan administrator determines that it will still be unable, for reasons beyond the control of the plan, to make the decision within the extension period, the plan may extend decision-making for a second 30-day period. The regulation requires that the plan provide a disability claimant with an extension notice that details the reasons for the delay. Thus, a plan may take, under limited and justifiable circumstances, up to 105 days to resolve a disability claim at the initial claims stage, provided that appropriate notice is provided to the claimant before the end of the first 45 days and again before the end of each succeeding 30-day period.

In the Department of Labor’s view, this framework will enable a plan to take sufficient time to make an informed decision on what may be a complex matter, but the plan will be required to keep the disability claimant well informed as to the issues that are delaying decision-making and any additional information the claimant should provide. By limiting the reasons for which decisions may be delayed, the regulation also requires prompt decision-making when appropriate.

For our experience we often see that claim decision range between 45-90 days as the disability carrier will continue to ask for additional information and claim they do not have sufficient information in order to render a claim decision. Furthermore, it usually takes several weeks for the disability company to obtain all of your medical records and then have their doctors review the records

There are 4 opinions so far. Add your comment now.

Marg:

How ling does the insurance company have to make the decision when the policy changes from own to any occupation once all documents are submitted and interview is complete.

Attorney Stephen Jessup:

Marg, typically responses are made within 45 days, but the most important aspect would be are they still paying your monthly visit while they continue their review? If they are, they could reasonably drag out their review.

Leslie:

Hello,

I’m helping my son who must live with me due to disabilities. I received a voice message today, on the 45th day of his appeal, by the Guardian Insurance plan administer, that “obviously we will need an extension as the nurse has JUST requested medical records” and she asked that my son PLEASE call her back. I suggested he wait.

They requested and received my son’s authorization for medical records over 30 days ago. When the admin requested the authorization back then, she said, “I don’t think we’ll need any more records, but send the authorization just in case….” (The appeal was very thorough.) Then the nurse called four business days ago to interview my son and asked if he wanted to get one of his doctor’s notes for her that weren’t included in the appeal. He responded that she already has his authorization on file to request them.

Is this last minute decision to request medical records considered “reasons beyond the control of the plan”? Looks more like they just dropped the ball. And what if they do not send notice in writing? Could they still send an email today, on the 45th day? Thank you for your help!

Attorney Stephen Jessup:

Leslie, without a better understanding of the entire claims process for the appeal we would not be able to comment as to sufficiency of the extension request, but we would highly recommend that you get any and all medical records needed to Guardian as soon as possible. It is ultimately the duty of the insured to provide medical records, and if Guardian does not have them at the time of the rendering of a decision and they deny the appeal you will not be able to get the records into the file for a judge to review. Please feel free to contact our office if you would like to discuss in greater detail.

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