Delays by the Insurance Company During an ERISA Appeal

The Regulations governing ERISA claims have time limits governing the claim and appeal process. According to the Regulations, a claimant has a minimum of 180 days to appeal a denied disability claim. An insurer must decide the appeal within 45 days, or if “exceptional circumstances,” exist, may request an additional 45 day period to decide the appeal.

Recently, we have seen insurers attempt to obtain additional time by delaying or “tolling” the appeal, while they purportedly obtain additional information from third parties (such as an “independent” medical examination). We believe that any delay due to a request for third party information is an insufficient basis to “toll” the time for conducting an appeal and is an improper delay of the appeal process.

The Regulations do permit an insurer to “toll” an initial claim, while they request and wait for records or information. However, once a claim has been denied and it has been appealed, an insurer may not extend the deadlines, by claiming that it needs additional information from third parties. Rather, the time for deciding an appeal may not be “tolled” unless the insured has failed to submit information to decide a claim. 29 C.F.R. 2560.503-h(i)(4).

Don’t let your insurance claims administrator take advantage of you, and delay the payment of your benefits longer than the law allows. Insist that they comply with the regulations and communicate with you in a timely manner. If you let them know that you are an educated consumer, the odds are that they will attend to your claim more carefully.

Of course, if you ever have any questions. Call us, we can help!

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