FILINGACIM
FORYOURDISABILITYBENEFITS
EMPLOYEE BENEFITS SECURITY ADMINISTRATION
UNITED STATES DEPARTMENT OF LABOR
This publication has been developed by the U.S. Department of Labor,
Employee Benets Security Administration (EBSA).
To view this and other EBSA publications, visit the agency’s Website at:
dol.gov/agencies/ebsa.
To order publications or speak with a benets advisor, contact EBSA
electronically at:
askebsa.dol.gov.
Or call toll free: 1-866-444-3272
This material will be made available in alternate format
to persons with disabilities upon request:
Voice phone: (202) 693-8664
TTY: (202) 501-3911
This booklet constitutes a small en ti ty compliance guide for pur pos es of the Small
Business Regulatory Enforcement Fairness Act of 1996.
FILING A CLAIM FOR YOUR DISABILITY BENEFITS
1
Introduction
If you participate in a workplace plan that provides
disability benefits, this booklet describes some of
your plan’s obligations and briefly explains the
procedures and timelines for filing a disability
benefits claim.
The Employee Retirement Income Security Act of 1974 (ERISA) protects
your disability benets and sets standards for those who administer your
plan. Among other things, the law and related rules include:
n Requirements for processing benet claims,
n The timeline for a decision, and
n Your rights when a claim is denied.
The rules for disability claims discussed in this booklet generally apply to people who receive
disability benets from a private-sector employment plan. However, there are exceptions:
U.S. DEPARTMENT OF LABOR
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n If your plan benets depend on someone other than the plan issuing a nding of disability; or
n For plans sponsored by government or most religious bodies.
For example, if, under the terms of a pension plan, the plan will pay benets to a person whom the
Social Security Administration or the employer’s long-term disability plan has determined to be
disabled, then the ERISA rules for pension claims would cover the claim for pension benets, not the
rules for disability claims.
If you’re not sure whether ERISA applies to you, contact your plan administrator for more
information.
Language Assistance
If you live in a county where 10 percent or more of the population is literate only in the same non-
English language, the plan must provide oral language assistance in that language and provide
written notices in that language upon request. In such counties, benet denial notices must include
a prominent statement in the relevant non-English language about the availability of language
assistance.
Reviewing Information from Your Plan
When you rst enroll in your employer’s plan, you will receive a document called the Summary
Plan Description (SPD). It provides a detailed overview of the plan: how it works, what benets
it provides, how to le a claim for benets, and any limitations that may apply. It also describes
your rights and responsibilities under ERISA and your plan. If you participate in a single-employer
collectively bargained plan, your claim ling, grievance, and appeal procedures may also be affected
by the collective bargaining agreement.
Before you apply for benets, review the Summary Plan Description to make sure you meet the
plan’s requirements for disability and understand the claim-ling procedures. Sometimes claims
procedures are contained in a separate booklet. If you do not have a copy of your plan’s Summary
Plan Description or claims procedures, contact your plan’s administrator, who is required to provide
you with a copy. Keep a photocopy or similar documentation of your request for your records.
Filing a Claim
An important rst step is to check your Summary Plan Description to make sure you meet your
plan’s requirements to receive benets. Also, be aware of what your plan requires to le a claim. The
Summary Plan Description or claims procedure booklet must include information on where to le,
what to le, and whom to contact if you have questions about your plan. If that information is not in
the booklets, write your plan administrator, your employer’s human resource department (or the ofce
that normally handles claims), or your employer to notify them that you have a claim. Keep a copy
of the letter for your records. You may also want to send the letter by certied mail, return receipt
requested, so you will have a record that the letter was received and by whom.
If an authorized representative is ling the claim on your behalf, your plan may require you to
complete a form to name the representative. The authorized representative must follow the plan’s
claims procedure in the Summary Plan Description.
When a claim is led, be sure to keep a copy for your records. Note: plans generally cannot charge
any money for ling claims and appeals.
FILING A CLAIM FOR YOUR DISABILITY BENEFITS
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Waiting For a Decision on Your Claim
ERISA sets specic time limits for plans to evaluate your claim and inform you of the decision. The
time limits are counted in calendar days, so weekends and holidays are included. Plans are required
to pay or provide benets within a reasonable time after a claim is approved, though ERISA does not
specify a time limit. Check your Summary Plan Description for how and when benets are paid.
Disability claims must be decided within a reasonable period of time. Generally, if you submit a
disability claim, then the plan must make a decision within 45 days of receiving the claim. There
are some circumstances that could extend the timeline:
IF... AND THE PLAN…
THEN THE PLAN CAN
EXTEND THE DEADLINE
FOR MAKING A DECISION…
The plan needs more time to
review, for reasons beyond its
control
• Tells you, within the initial 45-
day period, that it needs more
time,
• Explains why,
• Does not request any additional
information needed, and
• Tells you when it plans to make
a nal decision
Up to 30 days
• Tells you, within the initial 45-
day period, that it needs more
time,
• Explains why,
• Requests additional
information (in which case the
plan must give you at least 45
days to supply the information),
and
• Tells you when it plans to make
a nal decision
Up to 30 days after receiving the
information OR when the time
period to provide the information
ends, whichever comes rst
The plan still needs more time to
review after the rst extension
• Noties you before the rst
extension expires
Up to 30 days more
• Noties you before the rst
extension expires, and
• Requests additional
information (giving you at
least 45 days to supply the
information)
Up to 30 days after receiving the
information OR when the time
period to provide the information
ends, whichever comes rst
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For any additional extensions, the plan needs your consent. The plan must notify you whether your
claim has been denied before the end of the time allotted for the decision.
If your claim is denied, the plan administrator must send you a notice, either in writing or
electronically. The notice must include:
n A detailed explanation of why your claim was denied. If applicable, the notice must explain why
the plan disagreed with the views of a medical professional or vocational expert (including those
who treated you and those whose advice was obtained by the plan), or a disability determination
made by the Social Security Administration;
n A reference to the specic plan provisions on which the denial is based;
n A statement that you are entitled to receive copies of all documents relevant to your claim for
benets, upon request and at no cost to you;
n The plan rules, guidelines, protocols, standards, or other similar criteria relied upon in denying
the claim, or a statement that such documents do not exist; and
n A description of the plan’s appeal process, including the time limits involved, and a statement of
your right to pursue your claim in court if your claim is denied on appeal.
Appealing a Denied Claim
Claims are denied for various reasons. Perhaps you are not eligible for benets. Or, perhaps the plan
simply needs more information about your claim. Whatever the reason, you have at least 180 days to
le an appeal (check your Summary Plan Description or claims procedure to see if your plan provides a
longer period).
Use the information in your claim denial notice in preparing your appeal. Be sure to include in your
appeal all information related to your claim, particularly any additional information or evidence that you
want the plan to consider, and get it to the person specied in the denial notice before the end of the 180-
day period.
Reviewing an Appeal
On appeal, your claim must be reviewed by someone new who looks at all of the information
submitted and consults with qualied medical professionals if a medical judgment is involved. This
reviewer cannot be the same person who made the initial decision or that person’s subordinate, and the
reviewer must give no consideration to the initial decision.
Disability appeals must be reviewed within a reasonable period of time, but not later than 45 days after
the plan receives your request to review a denied claim. If the plan determines special circumstances
justify an extension, the plan may take up to an additional 45 days to decide the appeal. However,
before taking the extension, the plan must notify you in writing during the rst 45-day period
explaining the special circumstances, and the date by which the plan expects to make the decision.
FILING A CLAIM FOR YOUR DISABILITY BENEFITS
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There are two exceptions to these time limits:
n Single-employer collectively bargained plans generally may use a collectively bargained
grievance process for their claims appeal procedure if it has provisions on ling, determination,
and review of benet claims.
n Multiemployer collectively bargained plans have special timeframes to allow them to
schedule reviews on appeal of disability claims for the regular quarterly board of trustee
meetings.
If you are a participant in one of those plans and you have questions about your plan’s procedures, you
can consult your plan’s Summary Plan Description and collective bargaining agreement or contact the
Department of Labor’s Employee Benets Security Administration (EBSA) at
1-866-444-3272.
Your plan cannot deny your appeal based on evidence or rationales that were not included when
the benet was rst denied, unless you are given notice of the new information and a reasonable
opportunity to respond before the plan’s decision is due. For example, if, during consideration of
your appeal, the plan causes a new medical report to be generated, the plan must provide any new or
additional evidence in that report to you before the 45-day period expires and you must be given a
reasonable opportunity to respond.
Plans can require two levels of review of a denied disability claim to nish the plan’s claims process.
In such cases, the maximum time period for each review generally is half of the time period permitted
for one review. For example, a plan with one appeal level must review a disability claim within
45 days after the plan receives your appeal. If the plan requires two appeals, both reviews must be
completed within 45 days. If your appeal is still denied after the rst review, the plan must allow you a
reasonable period of time (but not a full 180 days) to le for the second review.
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Once the plan makes a nal decision on your claim, the plan must send you a written explanation of
the decision. The notice must include:
n A detailed explanation of why your claim was denied. If applicable, the notice must
explain why the plan disagreed with the views of a medical professional or vocational expert
(including those who treated you and those whose advice was obtained by the plan), or a
disability determination made by the Social Security Administration;
n A reference to the specic plan provisions on which the decision is based;
n Information on any additional voluntary levels of appeal;
n An explanation of your right to receive documents that are relevant to your benet claim free
of charge;
n The plan rules, guidelines, protocols, standards, or other similar criteria relied upon in
denying the appeal, or a statement that none exist; and
n A description of your rights to seek judicial review of the plan’s decision, including a description
of any applicable contractual limitations period and its expiration date.
If Your Appeal Is Denied
If the plan’s final decision denies your claim, you may want to seek legal advice regarding your
rights to challenge the denial in court. Normally, you must complete your plan’s claim process
before filing an action in court to challenge the denial of a claim.
However, you can immediately pursue your claim in court if your plan failed to establish, or does
not follow, the claims processing rules (unless the plan’s violation is minimal). If a court rejects
your request for immediate review of a denied claim, the plan must treat the claim as refiled on
appeal.
If you believe your plan failed to establish or follow a claims procedure consistent with the
Department’s rules, you may want to seek legal advice regarding your right to ask a court to
review your benefit claim without waiting for a decision from the plan. You also may want to
contact the nearest EBSA office about your rights if you believe the plan failed to follow any of
ERISA’s requirements in handling your benefit claim.
Additional Protections
Your plan must decide both claims and appeals in an independent and impartial manner. For example,
a person deciding your claim, or any medical or vocational expert involved in the decision, cannot
be hired, promoted, terminated, or compensated based on the likelihood that person will support the
denial of benets.
The rights discussed in this booklet apply also to certain rescissions (retroactive cancellations
or discontinuance) of disability coverage, for example due to alleged misrepresentations in your
application for coverage. Rescissions for non-payment of premiums are not covered by these rules.
FILING A CLAIM FOR YOUR DISABILITY BENEFITS
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Filing a Claim – Summary
n Check your plan’s benets and claims procedure before ling a claim. Read your Summary Plan
Description. Contact your plan administrator if you have questions.
n Once your claim is led, the maximum allowable waiting period for a decision is 45 days. Your
plan can extend certain time periods but must notify you before doing so. Usually, you will
receive a decision within this timeframe.
n If your claim is denied, you must receive a written notice, including specic information about
why your claim was denied and how to le an appeal.
n You have at least 180 days to request a full and fair review of your denied claim. Use your
plan’s appeals procedure and be aware that you may need to gather and submit new evidence or
information to help the plan in reviewing the claim.
n Reviewing your appeal can take up to 45 days. The law and the Department’s rules allow a
disability plan additional time if the plan’s administrator has notied you beforehand of the
need for an extension.
n If the appeal is denied, the written notice must tell you why it was denied, describe any
additional appeal levels or voluntary appeal procedures offered by the plan, and contain a
statement regarding your rights to seek judicial review of the plan’s decision.
n You may decide to seek legal advice if your claim’s appeal is denied or if the plan failed to
establish or follow reasonable claims procedures. If you believe the plan failed to follow
ERISA’s requirements, you can contact EBSA to discuss.
Resources
To view this and other EBSA publications, visit dol.gov/agencies/ebsa.
To order publications or request assistance from a benets advisor, contact us at
askebsa.dol.gov or
call toll-free:
1-866-444-3272.
EMPLOYEE BENEFITS SECURITY ADMINISTRATION
UNITED STATES DEPARTMENT OF LABOR
September 2018
