How Much Time Does Prudential Have to Make A Determination On an ERISA Disability Appeal?
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 appeal.
Resources to Help You Win Disability Benefits
Disability Benefit Denial Options
Submit a Strong Prudential Appeal Package
We work with you, your doctors, and other experts to submit a very strong Prudential appeal.
Sue Prudential
We have filed thousands of disability denial lawsuits in federal Courts nationwide against Prudential.
Protect Your Benefits
Get Your Prudential Disability Application Approved
We help claimants throughout the entire application process.
Prevent a Prudential Disability Benefit Denial
We manage every aspect of your disability claim following claim approval.
Negotiate a Prudential Lump-Sum Settlement
Our goal is to negotiate the highest possible buyout of your long-term disability policy.
Prudential Reviews
(656)
Policy Holder Rating
5
0%
4
0%
3
0%
2
53%
1
46%
Timely Payments
2.0out of 5
Handling Claim
2.0out of 5
Customer Service
2.0out of 5
Dependable
2.0out of 5
Value
1.9out of 5
Showing 8 of 656 Reviews
Prudential
Denied but Not Denied but I am Denied
I went out in Aug. 2022 for neck pain. After seeing a neurologist I had to get an ACDF C5-7, it was also determined I had carpal tunnel in my right hand and bulging disk i... read more >
Prudential
California State Disabilty "OFFSET" never mentioned or outlined when enrolling for STD coverage.
All terms and conditions of receiving a claim benefit not made available when enrolling. Hidden elements of eligibility... not fully transparent with issues that might eff... read more >
Prudential
Prudential terminated my LTD, so now I have no income
I was working at a shipyard at San Diego and hurt my back again while working. Hurt my back in the US Navy in 98 and had issues since then so I decided to get the surgery ... read more >
Reply
Prudential
Prudential cancelled my policy amid COVID crisis
In the mist of the covid crisis Prudential decided I needed to prove my disability, yet again. I have been physically disabled since 10/31/1989. I now know that I have bee... read more >
Reply
Prudential
I was sold a policy that I cannot use and no one will show me the policy
I had Prudential STD and LTD through my employer. I received my STD with no problem. Started receiving LTD for a while, then Prudential said I owed them because I receive ... read more >
Reply
Prudential
Prudential verbally approved my claim and then sent me a denial letter
I have been denied twice from Prudential for my LTD case. Back injury 2009 – knee injury 2011. Back doctor took me out of work (July 2018) due to me working 35 hrs per w... read more >
Reply
Prudential
It would cost me more to fight Prudential than to let them get away with their games
I’ve been thru all the same things everyone complains about here. I’ve always been one step ahead of their game due to research. I just got notice they are stopping my... read more >
Prudential
Prudential told me I would have a decision today, and now the need another week. Guess what, I'm still broke
Just called them and now they need another week and a half so they can do an occupational review on my job description or something like that. Even though the case manager... read more >
Reply
Answered Questions by Our Lawyers
(41)
Showing 8 of 41 Answered Questions
Q: I made a Short term disability claim with Prudential but they right away went to consider long term disability
A: Nick: Depending on the timing of when you filed the STD claim, the Elimination period for the LTD may have alr... Read More >
Q: Prudential denied me STD due to a doctor who wrote personal things about me, like I still drive.
A: We are sorry to hear about your denial. Please contact us and we will review your denial letter. We can discus... Read More >
Q: Prudential is sending me to an IME but refuses to allow recording. Should I refuse to go to the IME?
A: Mike:This is always a tough situation. You cannot refuse to go. I would show up with a witness and a recor... Read More >
Q: What can I do about my long term benefits that’s ending after 2 years?
A: Prudential is likely telling you that they will stop paying you in September because they either think you sho... Read More >
Q: My mother paid many years for a long-term care policy. When she had to be put in an assisted care facility, Prudential won't pay. Do you accept cases like this?
A: Allan, I am sorry to hear about Prudential’s long term care denial for your Mom’s care. We have handled ma... Read More >
Q: Can Prudential deny me if SSDI approves me?
A: Lauraine, unfortunately you can be denied even if SSDI approved you. If you need assistance managing your LTD ... Read More >
Q: How does Prudential calculate attorney fees?
A: Lomy, calculate attorney fees for what exactly? Under ERISA, the federal law that governs employer provided po... Read More >
Q: Can I sue my PRUDENTIAL LTD for the cost of hiring a disability attorney to get my benefits reinstated?
A: Loretta: Assuming the attorney was successful and got the denial overturned, the short answer is no you cannot... Read More >
Helpful Videos
(908)
Showing 12 of 908 Videos
Disability Benefit Tips
(331)
Showing 8 of 331 Benefit Tips
Prudential Lump Sum Disability Policy Buyout Options
If you're a Prudential long term disability insurance claimant who has been on claim for a month or two, you may be interested in getting a lump sum buyout of your insurance policy. But although Prudential does offer this as an option for many claimants, it's never obligated to buy out disability claimants - and when it comes to your lump-sum disability buyout o... Read More >
Is Exhaustion of Remedies Required before filing an ERISA Lawsuit?
In Deborah Holmes v. The Prudential Insurance Company and Bekaert Corporation, the Plaintiff was employed by the Bekaert Corporation (Bekaert) when she was injured at work. She filed a lawsuit unrelated to ERISA and her employer settled with her. In addition, Plaintiff and Bekaert entered into a separation agreement in which Plaintiff signed a general release of legal claims ... Read More >
What Should I Expect When Suing Prudential for a Disability Insurance Benefit Denial?
Disability benefit lawsuits against Prudential is a daily occurrence for our lawyers.In this video, disability insurance lawyers Gregory Dell and Rachel Alters discuss their experience in handling ERISA lawsuits against Prudential.... Read More >
Do I need to disclose my disability insurance claim if I filed for bankruptcy?
Do I need to disclose my disability insurance claim if I filed for bankruptcy?Yes. If you file for bankruptcy it is imperative that you disclose your disability insurance claim regardless of the stage that your claim is in - application, denial, appeal, pending litigation, etc.The Bankruptcy Code and Rules impose an express and affirmative duty on individuals filing for bankruptcy to disclose all asset... Read More >
Can I submit a long-term disability claim if my employment has been terminated?
It is not uncommon for employees to struggle and suffer through sickness or injury and work, even if working is counter-intuitive to their own health and effective productivity at their occupation. Unfortunately, these employees often find themselves as targets of work-force reduction or layoff, because despite their best efforts they are unable to keep up with their employer’s expectations and requirements.... Read More >
How Much Time Does Prudential Have to Make A Determination On an ERISA Disability Appeal?
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 st... Read More >
If I File A Short Term Disability Claim With My Carrier And My Claim Is Denied, Do I Also Need To File A Separate Long Term Disability Claim?
An issue that comes up often during litigation of a claim for disability benefits is: After exhausting all of your administrative remedies for a clam for STD benefits, may a lawsuit be brought for LTD benefits as well? Insurance companies frequently move to dismiss claims for LTD benefits, claiming that the Plaintiff failed to successfully appeal the denial of the STD claim, therefore the LTD claim was never a... Read More >
Can the disability company limit my disability benefits to 24 months if I have been diagnosed with depression as a result of my physical disability?
This is an issue that our disability lawyers face on an almost daily basis. Disability insurance companies, such as Prudential Insurance Company, will often argue that a claimant is disabled by a mental condition and not a physical condition. This is done so that they can limit the payment of disability benefits to a limited pay period of either 12 or 24 months.... Read More >
Dell Disability Cases
(375)
Showing 8 of 375 Dell Disability Cases
Prudential reverses decision to terminate LTD benefits of MRI Tech with Primary Progressive Multiple Sclerosis and degenerative Disc Disease
The claimant is a 58-year-old former MRI Technologist for Fairview Health Services who has long suffered from the debilitating effects of her chronic medical conditions. She has a history of neck pain as well as right arm pain and numbness dating back to 2005 with a reoccurrence of severe symptomatology in 2013. MRI of her cervical spine performed in August of ... Read More >
Engineer With Depression Wins Prudential LTD Appeal
The claimant is a former Senior Technology Services Engineer for Accolade, Inc. who was forced to cease working on May 25, 2021 and to apply for disability insurance benefits under his policy with Prudential because of severe symptomatology related to depression and anxiety. Prudential initially approved his claim for LTD benefits as his symptoms were demonstrat... Read More >
Dell Disability Lawyers Win Disability Insurance Appeal Against Prudential for KPMG Employee
Our client, a former Managing Director - Tax Consultant for KPMG contacted our office after his claim for short term disability benefits was denied by Prudential. He spoke with Attorney Stephen Jessup, who has handled multiple cases for KPMG employees whose disability benefits had been denied by Prudential. In this case our client had filed for disability due to... Read More >
Lawyer Wins 24 Month Mental Nervous Prudential Disability Denial
Our client, a former law partner of a large national law firm, filed for disability with Prudential due to severe mental health conditions that resulted in hospitalization. Prudential approved her claim for short and then long term disability benefits and in doing so asserted the 24 month limitation on benefits due to mental health conditions that was contained ... Read More >
Research Epidemiologist with chronic fatigue / ME wins LTD appeal against Prudential
Our client is a former Mental Health Epidemiologist who unfortunately suffered the progressive onset of pervasive fatigue, malaise, muscle aches, headaches, difficulty with concentration/focus, difficulty with information processing, and depression. Her symptoms were attributed to the medical diagnoses of chronic fatigue syndrome / Myalgic encephalomyelitis by her treating phy... Read More >
JP Morgan Chase Financial Advisor With Cancer Wins Prudential Long Term Disability Appeal
Our client was a 58 year old private client advisor for JP Morgan Chase Bank. He was forced to stop working due to squamos cell carcinoma of the mandibular jaw. He underwent numerous operations on his jaw including reconstruction, tracheostomy and postoperative radiation therapy. Apart from chronic pain suffers dysphagia and is limited in terms of... Read More >
Prudential Fails to Pay Long Term Disability Benefits of Claimant Suffering from Addison’s Disease
What is Addison’s Disease?Our client is a 43-year-old male who was employed as a Manager for Microsoft for many years. He was forced to discontinue working in his highly rewarding career after being hospitalized for progressively worsening symptoms of fatigue, nausea, dizziness, diffuse pain and weight loss (20-30 pounds) which was later deemed attributab... Read More >
Successful Appeal Against Prudential Gets Breast Cancer Survivor Back on Claim for LTD Benefits
Nearly ten years after initially beating breast cancer, our client was distraught to hear that she had a reoccurrence of the disease in 2015. She quickly underwent a left mastectomy, chemotherapy and radiation therapy, followed by a course of lymphedema therapy. In 2016, she had expander placement but unfortunately she suffered from a non-healing wound in her left chest from the expander that had to eventually... Read More >
Disability Lawsuit Stories
(765)
Reviews from Our Clients
