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What Is Proof of Loss in ERISA Long-Term Disability Insurance Claims?

Filing for monthly benefits from an employer-sponsored (ERISA) long-term disability insurance policy can often be a complex and difficult process. One of the first requirements you’ll face is the submission of “proof of loss” documents to your long-term disability insurer.

As the name suggests, proof of loss is the information you provide to your insurance company that proves you have an illness or injury and that it rises to the level of disability, as set out in your policy. In practice, though, there can be differences between given policies and insurance companies when it comes to what actually constitutes actual proof of loss in an ERISA claim.

Making a mistake here could be fatal to your claim, so it’s crucial to understand how proof of loss works.

What Is Proof of Loss?

To learn exactly what proof of loss (also known as proof of claim) you’ll need, you’ll have to research your own policy document, ideally with the assistance of an award-winning ERISA disability insurance lawyer. Typically, necessary items may include:

  • A personal statement about your condition, outlining how it prevents you from doing full- or part-time work,
  • A statement from your employer,
  • Medical records and reports from your physician and any other healthcare provider who has treated your disabling illness or injury, plus a certification of your disability
  • Evidence of the date on which your disability began,
  • Evaluation records from any vocational expert who has assessed your disability in terms of your reduced capacity in the workplace.

While your disability insurance company has the right to decide on what kind of proof of loss it requests, the courts have imposed limitations. Legally, the proof of loss requirements your disability insurer proposes must be reasonable, or they may be legally unenforceable. The limits of reasonableness here may depend on the federal court jurisdiction in which you live.

It’s also important to realize that the precise nature of proof of loss requirements will depend on the particular illness or injury you’ve sustained. For example, if it’s not certain whether your symptoms arise from a physical or a psychological issue, your insurer may require you to undergo neuropsychological testing to ascertain the root cause of your condition. The difference between physical and mental nervous conditions is especially significant in the context of long-term disability insurance as there is generally a 24-month limit on the monthly benefits you may recover in respect of the latter.

Submitting Proof of Loss as Part of Your ERISA Disability Insurance Claim

The first item that’s usually required as part of the ERISA long-term disability claims process is the notice of claim. This is a relatively simple collection of documents you must complete and return to your insurer within 20-30 days of the onset of your disabling illness or injury.

After the notice of claim, the proof of loss is the next part of the process. Policies commonly require the submission of proof of loss documentation within 60-90 days of the onset of your disability.

Proof of loss may become due after the elimination period (also known as the waiting period) on your long-term disability insurance policy. These periods vary from one plan to the next; on group disability employer-sponsored policies, they typically run for between 90-180 days. The clock generally starts to run on your elimination period on the day your physician certifies you as being disabled, per your policy’s definition of disability. You may not become eligible to start receiving monthly benefits from an ERISA disability policy until this period elapses.

What Happens If You Miss the Proof of Loss Deadline?

As is the case with many aspects of the ERISA long-term disability insurance claims and appeals processes, strict deadlines apply to the submission of your proof of loss documentation. The specific deadline that will apply to you will depend on the wording of your policy. Your insurer may return your proof of loss form to you for revisions if there is some issue with it, such as your failure to include a key medical record or a missing signature, or they may not.

You should be aware that your group disability insurance company may be entitled to deny your claim outright if you miss your proof of loss deadline.

Getting Help From an Award-Winning ERISA Disability Lawyer Before You Submit Your Proof of Loss Documentation Companies

providing employer-sponsored long-term disability insurance coverage do their best to make things complicated for claimants in the hope they will make mistakes, allowing for the delay or outright denial of monthly benefits. The proof of loss process under ERISA can be straightforward with the help of an expert Boston ERISA disability attorney, but fatal errors are much more common when claimants approach it by themselves.

Don’t make this mistake. Contact DarrasLaw today for a free initial consultation, including a free policy analysis or claim assistance. If you’ve already received an initial claim denial on your employer-sponsored policy, you need to begin compiling a comprehensive administrative appeal as soon as you can to get it back to your insurer ahead of the deadline.

DarrasLaw is Americas' most honored and decorated disability litigation firm in the country. Mr. Darras has seen more, evaluated more, litigated more, and resolved more individual and group long term disability and long-term care cases than any other lawyer in the United States.

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