Your monthly disability check from your employer’s group disability insurance plan (some people call this being “on claim”), hasn’t arrived as scheduled.
What can you do?
You should start by calling your adjuster and asking why there has been a delay.
If the adjuster ignores you or does not provide a reasonable answer, you may be allowed to file a lawsuit to get your check. But when can you file suit?
How Long Does a Group Disability Insurer Have to Pay a Claim?
First, It’s important to understand how long a group disability insurer has to pay a claim.
Group disability plans are governed by a federal law called ERISA, the Employee Retirement Income Security Act. The Department of Labor has regulations that govern these plans.
ERISA regulations clearly explain that a group disability plan administrator has 45 days to pay a claim.
Specifically, 29 CFR 2560-503-1(f) states: (3) Disability claims. In the case of a claim for disability benefits, the plan administrator shall notify the claimant, in accordance with paragraph (g) of this section, 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 plan administrator both determines that such an extension is necessary due to matters beyond the control of the plan and notifies the claimant, 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.
What that means is that a group disability insurer has 45 days to pay a claim or request an extension.
If you are waiting for your check, that means that the insurance company can wait a month and a half before it has to send your check or tell you if it is terminating your benefits.
What happens if the disability insurance company does not pay the claim within 45 days and does not ask for the 30-day extension allowed by the regulation? That is a denial – an “adverse benefit determination” and you can sue them.
ERISA Regulation 29 CFR 2560-503-1(m)(4) clearly states that an “adverse benefit determination” includes:
(i) Any of the following: A denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant’s or beneficiary’s eligibility to participate in a plan. So if a group disability insurance company does not send you your monthly disability check within 45 days of the day it was due, and it does not ask for an extension, and does not issue a letter terminating benefits, your claim is deemed denied, and under another section of the regulation, 29 CFR 2560-503-1(l), you may skip any appeals that are required by the plan and file a lawsuit.
It is important to understand that if the insurance company issues a denial letter, you must pursue an internal appeal before you file a lawsuit, but if no denial or termination letter is sent, you are free to sue the disability insurance company when it fails to send your disability check within the time allowed by the federal regulations.
If you find yourself in this situation, Tucker Disability Law can help you. We have over 30+ years of experience filing lawsuits against the insurance companies and we have a 98% win rate.
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At Tucker Disability Law we don’t settle for less. Neither should you.
