A disability appeal denial must be timely or it may result in the appeal being deemed denied. Prudential recently lost a case where the Court found that its untimely decision of an appeal meant the appeal was essentially denied. Under ERISA, there are certain steps that must be followed before a lawsuit can be filed. This includes exhausting all administrative remedies, including appeals.
Submitting an appeal of a denial or termination of long-term disability benefits is how a person exhausts administrative remedies. In the case with Prudential, the claimant, Jaclyn Wiley, was allowed to proceed with the lawsuit against Prudential even though a decision of the disability appeal had not been made. The insurance company’s tardiness was essentially a denial of the appeal.
Wiley appealed the insurance company’s decision of her initial claim in December. Instead of processing the appeal, Prudential repeatedly set new deadlines. This is a violation of the express timeframe allowed under ERISA law. While Prudential initiated extensions, Wiley submitted additional medical records supporting her total disability. A decision still had not been made by the following February. Wiley filed a lawsuit against Prudential alleging a violation of ERISA. The insurance company moved to dismiss the case claiming administrative remedies had not been exhausted. They claimed the lawsuit was filed prematurely.
The Court disagreed with Prudential, finding the extension of deadlines were neither requested by Wiley nor allowed under ERISA. As a result, Prudential did not make a timely decision on Wiley’s appeal. Thus, they said the claim was exhausted and the lawsuit was properly filed in court.
As can be seen, disability benefits that are governed by ERISA require special attention. Many stages in the process are time sensitive. Specifically, the insurance companies are required to follow express timelines when making a long-term disability claim or disability appeal decision. For this reason, you should not try to handle your disability case alone. Consult with a seasoned long-term disability attorney to evaluate your case.
