Four Things the Insurance Company Does Not Want You to Know about Your Short and Long Term Disability Claim under ERISA

By: W. Chad Winebarger
Charlotte, North Carolina ERISA Attorney
The Bollinger Law Firm, P.C.

If you have short and long term disability benefits through your employer, the Employment Retirement Income Security Act (ERISA) will likely apply to any claim for benefits that you make. Below are four things that the insurance company may not want you to know about your claim:

  • If your claim is denied, you should immediately request in writing, via Certified Mail Return Receipt Requested, a copy of your claim file, policy, and summary plan description from both the insurance company and your employer. A plan administrator has 30 days to provide you with these documents. The plan administrator is usually either your employer or the insurance company. If the Plan Administrator fails to provide you with these documents within 30 days, the Plan Administrator may face a penalty of up to $110 per day until the documents are provided to you.


  • If your claim is denied, the insurance company must give you the opportunity for a full and fair review of your claim. For example, after you receive notification of the denial, the insurance company is required to give you 180 days to file an appeal. Also, the insurance company is required to consider all documents you submit, even if the insurance company already considered the information in its initial decision to deny your claim for benefits.


  • Proper handling of the administrative record is extremely important! Do not simply write a one-page appeal letter and expect the insurance company to overturn its denial. The administrative appeal, for the most part, is your day in court! In most cases, the Court will only review the documents and evidence that the insurance company used in reviewing your claim. Therefore, if your case goes to court, you will likely not be able to submit additional evidence or call witnesses to testify on your behalf.


  • In most denied claims, the insurance company will ask a doctor to review the medical records in your claim file. In the majority of cases where an outside doctor is asked to review the file, the doctor has never seen or treated you. The reviewing doctor inevitably forms opinions that are favorable to the insurance company's position. Unfortunately, a plan or claim administrator is not required to give any greater weight to your own treating doctor/s than the reviewing doctor. This is another reason why the proper handling of the administrative record is so important.

If you would like more information on short and long term disability claims under ERISA, please contact me at the Bollinger Law Firm, PC at 1-866-218-4759 or at cwinebarger@bollingerlawfirmnc.com.

The above statements should not be construed as advice for a specific situation. You should consult an attorney regarding your specific situation.