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How Much Time Does Prudential Have to Make A Determination On an ERISA Disability Appeal?

Attorney Rachel AltersAuthor: Attorney Rachel Alters

The amount of time that an insurance company is allotted to provide a decision for an ERISA disability appeal is often confusing to claimants and can be for attorneys as well. Insurance companies frequently drag out the ERISA appeals process beyond the allotted 90 days by requesting additional documentation, providing unwanted extensions and sending the claimant for independent medical testing. The question still remains as to how much time the insurance company is allowed to take to make a determination once the appeal is submitted. The answer is, usually 45 days and an additional 45 days for special circumstances, however, it depends on the individual facts of each claim. This very issue was addressed in the recent case of Wiley v. Prudential. The Plaintiff brought suit against Prudential alleging that her administrative remedies had been exhausted since Prudential never reached a decision within the proper timeframe allotted under ERISA (90 days from the date of filing).

In Wiley, the Plaintiff timely filed an appeal on December 14, 2015. Instead of processing the appeal, Prudential repeatedly set new deadlines-each time on its own initiative-giving the Plaintiff extra time in which to submit additional documents to support her appeal. However, Prudential never requested additional time to conduct its own investigation. When Prudential failed to rule on her appeal by February 2016, Plaintiff filed suit alleging violation of ERISA. Prudential filed a motion to dismiss alleging Plaintiff failed to exhaust her administrative remedies. The Court denied Prudential’s motion and stated the following:

To determine if Plaintiff’s claim should be deemed exhausted, the court must ask whether Prudential complied with ERISA. See Barboza, 452 F.3d at 1077. More specifically, the question here turns on whether Prudential complied with the regulation governing the time requirements for review of a denied disability claim. That regulation provides that “the plan administrator [2] shall notify a claimant . . . of the plan’s benefit determination on review within a reasonable period of time, but not later than [45] days after receipt of the claimant’s request for review by the plan.”

29 C.F.R. § 2560.503-1(i)(1)(i), § 2560.503-1(i)(3)(i) (setting an initial 45-day review period for disability claims). The plan administrator may, however, extend the initial review period under “special circumstances.” Id. § 2560.503-1(i)(1)(i), § 2560.503-1(i)(3)(i). For disability claims, a “special circumstances” extension can last no more than an additional 45 days “from the end of the initial period.” Id. § 2560.503-1(i)(3)(i). The administrator must provide the claimant with written notice of the extension before the expiration of the initial review period. See id. §2560.503-1(i)(1)(i).

The ERISA regulation also defines when the clock starts to run on an administrator’s review of a denied benefits claim: [T]he period of time within which a benefit determination on review is required to be made shall begin at the time an appeal is filed in accordance with the reasonable procedures of the plan, without regard to whether all the information necessary to make a benefit determination on review accompanies the filing.

Id. § 2560.503-1(i)(4). It further provides that [i]n the event that a period of time is extended as permitted [under the regulations] due to a claimant’s failure to submit information necessary to decide a claim, the period for making the benefit determination on review shall be tolled from the date on which the notification of the extension is sent to the claimant until the date on which the claimant responds to the request for additional information.

The Court found that the Plaintiff timely filed her appeal by December 14, 2015, even though she did not submit all the necessary records by that date.

The regulations plainly state that an appeal is timely filed so long as it is filed in accordance with the reasonable procedures of the plan, “without regard to whether all the information necessary to make a benefit determination on review accompanies the filing.” 29 C.F.R. §2560.503-1(i)(4).

Prudential’s letters to the Plaintiff voluntarily giving her multiple extensions to submit additional information did not toll the time for Prudential to make a determination as it was not a request on their behalf for additional review time. Plaintiff’s continual submission of additional records did not toll the time period to make a determination and is “perfectly consistent with the regulations.”

An appeal is deemed filed “without regard to whether all the information necessary to make a benefit determination on review accompanies the filing.” 29 C.F.R. § 2560.503-1(i)(4). The regulation says nothing that would foreclose a claimant from submitting records after the review period has begun. To the contrary, by not requiring the submission of all records to start the review period, the regulations contemplate that very practice.

Prudential was not permitted to delay the start of the appeals process for months after the Plaintiff timely filed her appeal so that Plaintiff could continue to submit additional documents. Especially in light of Plaintiff’s attorneys’ repeated objections to each unilateral extension given by Prudential. The fact that additional information was submitted by Plaintiff after the appeal was filed was irrelevant. Prudential took way beyond the allotted 45 days plus an additional 45 days for special circumstances to make their determination, therefore, Plaintiff exhausted her administrative remedies and the lawsuit was properly filed.

We deal with Prudential’s attempted APPEAL delays on a daily basis and make a determination on a case by case basis as to whether a lawsuit should be filed at the expiration of 45 days. Please contact us if you would like assistance with your Prudential disability claim.

There are 2 opinions so far. Add your comment now.

Shh:

Is there anything out there that defines what those special circumstances actually are? It feels like whenever I have to wait for a decision from them that they’re dragging their feet, almost as an intimidation tactic (might not be the right term). Your last paragraph mentions whether a lawsuit should be filed after 45 days. Have you had any instances where, for example, Prudential requests another 45 days but you file suit because the only special circumstance is that they waited until closer to the 45 day deadline to start looking over an appeal?

Attorney Stephen Jessup:

Shh, typically, no. The time it does happen is when there is no response at all within the 45 day period.

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