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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 18 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.

Jane:

I have requested an appeal with the standard insurance company. Around 40 days passed when i recevied an email stating they were requesting medical records from my doctors. I sent them my records I could acess from the patient portal. after a few weeks I received another email stating they were requesting them because they wanted the doctors notes. I got thr records and sent them which they verified. when i questioned the time frame i was told they stopped the clock after the first 45 days and now will be extending another 45 days. When 105 days passed i asked again and was told now thier doctor has to review the records and it will be another 3 weeks. Are they alllowed to take as much time as they want? I requested the policy from two people and was ignored by both.

Attorney Stephen Jessup:

Jane, Standard has an initial 45 day timeframe with which to render a decision on an appeal with the possibility of a 45 day extension. However, there can be periods where time timeframe is tolled, to include – waiting on information from you (or in some cases your doctors) or if new information is provided during the course of the review. Please feel free to contact our office to discuss your claim in greater detail.

Michelle:

I have Met Life too! STD ended 1/8/18 they have had ALL of my info FROM MY Doctors since 11/28/17, I’m told by the General disability operators that have combed through my account that they were waiting on an email back from a corporate HR PERSON, I AM CORPORATE & I know the person they emailed hasn’t been with my company for some time, then the person answering the call connected to the case worker they tell me my claim is with a ( nurse) who is trying to make a decision which makes absolutely no sense and she refuses to give me a date when she thinks that that nurse might have an answer to whether she can approve the Longterm Disability or not.

Now remember 2 doctors and specialist have disabled me 100% indefinitely I can do nothing surgery is going to be scheduled soon but they had testing to do before surgery was scheduled. My last day of work was 7/10/17.

Thank you.

Attorney Alex Palamara:

Michelle,

I am sorry that MetLife has not given you an answer yet on your claim for LTD benefits. They have a total of 105 days to do so if they take their extensions. However, due to the fact that STD was full paid through the end and the type of support that you describe, I would expect an answer in the near future. Of course, their time frame can be tolled if they are waiting on information, so it might be in your best interest to inform them that the person they called is no longer with the company and maybe provide them with that person’s replacement. If they do make the incorrect decision and deny your claim, please contact us at once to assist you in getting you on claim.

Jenny:

After requesting the plan document in full, and a copy of both my short and Longterm disability file, how many days does Cigna have to respond to the request or produce it. They ended my Longterm disability when the plan changes after it’s been paid for 24 months and the definition of disability changes. I sent it by certified mail and faxed it. Obviously I’m going to appeal the decision just like I had to at the start of both short term and long term disability. It took over 9 months to have the initial Longterm disability claim overturned and to receive a cheque. I have no other means of support and to put it mildly I won’t survive another 9 months without.

Attorney Alex Palamara:

Jenny, after a denial of a claim, the ERISA laws give the insurance company 30 days to supply the requested disability claim file. If you would like a free consultation to discuss your claim and the administrative appeal, please do not hesitate to contact. We may be able to be of assistance.

Lynette:

My employer still hasn’t submitted their portion of the long term disability claim form to the insurance company. All other items needed for the claim have been submitted by me and my doctors.

According to the insurance company, my claim will be closed if they don’t receive that form from my employer within 30 days of opening the claim. That 30 day period ends in five days. That means I will need to start over again with a new claim.

Do I have any recourse if my employer’s foot-dragging causes my claim to be closed?

Attorney Cesar Gavidia:

Lynette, it is unusual that the disability insurer would deny the disability claim on account of the employer not submitting the Employer Statement. I do not believe that the insurer can deny the claim on that basis alone, since they Plan Administrator is the employer and they have delegated their decision making authority to your disability insurer. Please call in to our office and ask to speak with a disability insurance attorney to discuss your options.

Ron:

I’m with Met life and been on their short term disability with back fusion running out 5/7/18. They have all my doctors info for the long term disability claim. Any idea how long it will take the same carrier as my St dis to make a long term dis decision? Do they then follow up every couple months or so? My doctor has me out now until end of June when I see him again.

Attorney Rachel Alters:

Ron,

Unfortunately there is no way to predict how long it will take for your LTD claim to be approved. There is no specific timeline that MetLife is required to follow other than it should be reasonable. It is a separate department and they will be doing an entirely new claim review to determine if you are disabled under the terms of the LTD policy. If approved they may ask for records every 3-6 months. IF you are on LTD for an extended period then they may review the claim every year. If for some reason you are not approved, please contact my office and ask for attorney Rachel Alters. Good luck.

Steph:

How long does an LTD company have to send payment after notification of approval? My policy falls under ERISA, so I realize that “good faith” is very limited…

Attorney Alex Palamara:

Steph, they have a “reasonable” period of time to send payment after a notification of approval. My thoughts are that they should pay within 30 days or give a very good reason why they have not.

Sue:

Hello. I have been trying to get my LTD since February 2018 the insurance keeps asking for medical records over and over. Now that they have them I get a letter asking for records from a dr. that has retired and there is no way to retrieve my records since he was a private pactice. Now they said they can deny my claim due to that? I was not seeing this dr. for the claim so why does it matter?

Attorney Alex Palamara:

Sue, I am sorry to hear of your issues getting LTD benefits. While they have a right to investigate their claim, if you have enough evidence to prove your claim, they shouldn’t be denying your claim for this reason. Please contact me so that we can discuss your claim and potential options for you.

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