Supplemental Security Income (“SSI”) benefits are paid by the federal government to qualified individuals, generally who are aged 65 and over, and/or who are disabled. In order to qualify for SSI, applicants must have both limited income and assets.

In terms of disabilities, SSI disability payments are reserved specifically for those who are disabled, and have limited assets and income as a result of their disability. People who have worked for an amount of time that is considered to be sufficient to qualify for social security retirement payments will not be eligible for SSI disability payments. Additionally, SSI disability payments differ from Social Security Disability Insurance (“SSDI”) benefits payments.

In order to be eligible for SSDI payments, an applicant must be disabled, in addition to having worked for a sufficient amount of time. And, they must have paid social security taxes. In comparison, those who receive SSI disability payments have not worked long enough to qualify for SSDI; in some cases, people who have never worked may be eligible for SSI disability.

Specific basic requirements include that the applicant must:

  • Meet the Social Security Administration definition of disabled;
  • Have limited income and resources;
  • Be a citizen, a U.S. national, or an eligible non citizen; and
  • Reside in the U.S. or the Northern Mariana Islands.

What Is ERISA? How Is ERISA Associated With Disability Benefits Claims?

In short, ERISA provides minimum standards for things such as funding and vesting of plans. The Employment Retirement Income Security Act, or “ERISA,” has been in effect since September of 1974. The Act was intended to create reform for the pension and retirement plans of people who work in the private sector, as well as to prevent abuse of those plans by their administrators. ERISA requires that there be clear information available to the plan owners, regarding the details of their plans:

Some examples of the types of information that is required to be provided include, but are not limited to:

  • General features of the plan;
  • How the plan is funded, i.e. does the employer match the amount their employee contributes as is common;
  • Length of service, as generally an employee must work for their employer for a specific amount of time before they can participate in the plan;
  • Minimum contribution amount, as employees who participate in the plan must generally meet the minimum contribution required;
  • Time of vesting, as employees must also work for a specific amount of time before being granted access to their share of the funds. It is important to note that they generally do not receive the employer’s contribution if they take the funds out before their retirement;
  • Process for appealing; and
  • A notification of participant’s right to sue, so that they may file suit if the appeals process fails.

If an employee has an issue with their employer’s disability benefits plan, they must file a disability claim internally before pursuing a case in a court of law. This is because ERISA also regulates disability and health benefits plans that are offered to employees by private employers.

What Materials Should Be Reviewed Prior To Pursuing A Disability Claim?

Employees who are filing for disability benefits must be familiar with several sources of information, the most important of which would be the disability plan’s summary description (or “SPD”) A standard SPD contains the following information:

  • An employee’s rights under ERISA;
  • The responsibilities of employers in terms of disability claims and benefits;
  • A general outline of how your employment-based disability plan operates;
  • A description of your plan benefits, as well as qualifying criteria; and
  • A description of how and when benefits will be paid out to qualifying employees.

In addition to the summary plan description, more information may be found in a booklet that is supplied by your employer. If employee-employer collective bargaining has occurred, you may need to read the appropriate sections of the collective bargaining agreement to determine how that may affect your options in terms of pursuing a disability claim.

After Filing, How Are Disability Claims Decided?

The review of your claim will depend on its category. Depending on the nature of the claimed disability, your claim could be assigned to a category that you had not anticipated. An example of this would be how claims for serious health issues may not be designated as “disability” claims.

However, if you are filing a true disability claim, the following time frame and guidelines will generally apply:

  • Decisions must be made within 45 days from receipt of the claim;
  • If more time is needed, the plan is required to notify you;
  • A notification must be provided, explaining why more time is needed;
  • An extension may be granted for up to 30 days;
  • If more information is requested, you generally must provide it within 45 days of the request for information;
  • Once again, the plan will have up to 30 days from the receipt of your new information in which to decide;
  • After the first 30 day extension, another extension may be made if notice is sent to the claimant; and
  • Any additional extensions require the applicant’s consent.

What Is The Appeals Process For Denial Of A Disability Benefits Claim?

If your disability claim gets denied, you must be notified of that denial. This notice must contain an explanation as to why your disability claim has been denied, as well as how to appeal this denial.

In order to prepare for the appeal process, you should first refer to the materials you have already been provided with; however, you can also request more relevant materials. An example of this would be how you may request relevant records from your plan, free of charge. Additionally, you can request the names of any medical professionals that are involved in the claim’s denial.

Generally speaking, the time frame for appeal is within 180 days of denial. However, your plan booklet or SPD may provide a specific time frame. The timeline is similar to that of the initial filing of the claim in that the appeals process allows for a 45 day window, and a 45 day extension may be given. Once again, a different time frame may be used for collective bargaining agreements. Additionally, the applicant must receive a written notification of the decision.

Once an appeal has been denied by the plan, an employee may seek a court judgment regarding their disability benefits. However, it is important to note that there are some circumstances in which an employee may be able to go to court without going through the appeal process. An example of this would be if an employee believes that the disability or health plan is not adhering to ERISA rules, and does not utilize a fair process when addressing the claims of employees.

Do I Need An Attorney For Denial Of A Disability Benefits Claim?

If you are an employee needing to file a disability claim, appeal the denial of your disability claim, or seek judicial review for your claim, you should consult with an experienced and local workers compensation lawyer. An attorney can advise you regarding your rights and legal options according to your state’s specific employment and disability laws. Additionally, your workers compensation attorney will also be able to represent you in court, as needed.

To reiterate, if your plan does not comply with ERISA and lacks adequate procedures for disability benefits claims, it may not be necessary to go through the internal appeal process. An attorney can help you get your claims reviewed by the court in a considerably smaller amount of time.