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How to determine the claim filing date


loch1
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hi,

In my ERISA LTD plan, the insurer is adding about 7 days to the documented date the claim was faxed to them for "processing time". Obviously this then gives them 52 days to respond rather than 45. Is this legal? The SPD does not seem to address this.

 

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46 minutes ago, loch1 said:

hi,

In my ERISA LTD plan, the insurer is adding about 7 days to the documented date the claim was faxed to them for "processing time". Obviously this then gives them 52 days to respond rather than 45. Is this legal? The SPD does not seem to address this.

 

Yes it may be legal.  See the link below for more info.

https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/publications/filing-a-claim-for-your-disability-benefits.pdf

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It may not just be the Summary Plan Description (SPD) - there may be a Summary of Material Modifications (SMM) that was provided - essentially an addendum/modification to the SPD - that you might not have reviewed. The DOL issued updated disability claims regulations that might apply to your plan. Check with your Plan Administrator,or check your records/website/whatever to see. A sample of general language (and there are many variations) :

In the case of a claim for disability benefits, if disability is determined by a physician (rather than relying upon a determination of disability for Social Security purposes), then instead of the above, the Administrator will provide you with written or electronic notification of the Plan's adverse benefit determination within a reasonable period of time, but not later than 45 days after receipt of the claim by the Plan. This period may be extended by the Plan for up to 30 days, provided that the Administrator both determines that such an extension is necessary due to matters beyond the control of the Plan and notifies you, prior to the expiration of the initial 45‑day period, of the circumstances requiring the extension of time and the date by which the Plan expects to render a decision. If, prior to the end of the first 30‑day extension period, the Administrator determines that, due to matters beyond the control of the Plan, a decision cannot be rendered within that extension period, the period for making the determination may be extended for up to an additional 30 days, provided that the Administrator notifies you, prior to the expiration of the first 30‑day extension period, of the circumstances requiring the extension and the date as of which the Plan expects to render a decision. In the case of any such extension, the notice of extension will specifically explain the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision on the claim, and the additional information needed to resolve those issues, and you will be afforded at least 45 days within which to provide the specified information.

 

P.S. - if anyone really wants to delve deeply into it...

https://www.federalregister.gov/documents/2016/12/19/2016-30070/claims-procedure-for-plans-providing-disability-benefits

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  • david rigby changed the title to How to determine the claim filing date

the SPD is updated every year and i have the latest version. i don't see anything about what happens if they fail to respond in the 45 day timeframe.  all it says about filing and the 45 days is this"...shall notify you of the claim determination within 45 days of the receipt of your claim. "

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Given the relief in DOL Notice 2020-01, it would seem a plan/fiduciary/employer could take the position that it has additional time to respond to a claim or appeal during the COVID-19 outbreak.  That Notice states:

 “In addition to the relief provided in the joint notice, the Department is separately announcing in this notice an extension of deadlines for furnishing other required notices or disclosures to plan participants, beneficiaries, and other persons so that plan fiduciaries and plan sponsors have additional time to meet their obligations under Title of I ERISA during the COVID-19 outbreak. This extension applies to the furnishing of notices, disclosures, and other documents required by provisions of Title I of ERISA over which the Department has interpretive and regulatory authority, except for those notices and disclosures addressed in the Section 518 joint notice issued by the Department and the Treasury Department/IRS. Subject to the duration limitation in ERISA section 518, an employee benefit plan and the responsible plan fiduciary will not be in violation of ERISA for a failure to timely furnish a notice, disclosure, or document that must be furnished between March 1, 2020, and 60 days after the announced end of the COVID-19 National Emergency, if the plan and responsible fiduciary act in good faith and furnish the notice, disclosure, or document as soon as administratively practicable under the circumstances.”

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1. I don't believe the COVID emergency relieves the plan administrator of the responsibility of responding within 45 days to a disability claim. There is  a 30 day extension available to an plan administrator if the extension is required for reasons outside the control of the plan. COVID likely qualifies. "Processing time" does not. 

2. The question on whether the ERISA and plan mandated timeline is met matters if you want to go ahead and sue for your disability benefit. If you have no intention of retaining a lawyer at this point in time, the 7 day extension is something of a "so what". But it will be helpful in any later litigation.

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