After paying premiums faithfully for years, you’ve suffered a disabling condition, filed a claim and it has been denied. What should be your next steps? The outcome of your claim will affect your life, your finances, and future.
If your initial claim for long-term disability (LTD) benefits has been denied by your insurance company, you shouldn’t give up. All LTD policies provide for at least one, and often two, levels of administrative appeals, and it is through the appeals process that many workers eventually receive their benefits. While it might seem unlikely that the same insurance company that denied you initially will approve you on appeal, the appeals are evaluated by different claim units who sometimes disagree with the initial decision.
If your LTD plan is a group plan provided by your employer, you’re required under federal law to exhaust all your administrative appeals if you want to file a lawsuit against your insurance company in federal court. Even if you have an individual plan not governed by federal law, you should still exhaust all your administrative appeals. There’s no sense in passing up an opportunity to prevail on your case early in the process, without having to file a lawsuit.
Here are some things to keep in mind if you’re planning on appealing a denial of long-term disability.
Read and Understand Your Denial Letter
Your denial letter will address why your claim was denied and how to file an appeal. Pay close attention to the exact reason you’re given for denial, as this can affect how you proceed with your appeal. For example, if you were denied because your condition lacked objective documentation, you might want to submit additional x-rays or MRIs.
The denial letter will also discuss the various deadlines and requirements for filing your administrative appeals. A missed deadline or improperly filed appeal can provide an easy excuse for your insurer to deny your claim, so make sure that all your paperwork is submitted on time. Under federal law, your insurer must give you at least 60 days to file an appeal, but many LTD policies allow for more time.
Immediately after you receive your denial letter, you should request, in writing, a copy of your claim file from your LTD insurance company. The insurance company is required to provide you with a free copy, under federal law.
Stack the Administrative Record While You Can
The vast majority of employer-provided LTD policies are subject to a federal law known as ERISA, the Employee Retirement Income Security Act. Under ERISA, once you’ve exhausted all your administrative appeals, the “record” in your case is closed. This means if your case ends up in federal court because you file a lawsuit against the insurance company, the judge will be limited to considering only the evidence that was in your claim file for the administrative appeals, and not any newly submitted evidence.
It is critical, therefore, that you stack the administrative record with as much favorable evidence as you can while the record is open. What kind of additional evidence should you submit? First, you should make sure that your file already contains all your relevant medical records, including physician notes, radiology and surgical reports, and emergency room records. If anything is missing, you’ll need to request it and send it to your insurance company for consideration.
You should also try to obtain an opinion from your doctor on your physical and/or mental limitations. Be sure to ask your doctor specific questions related to your impairments and how they affect your daily activities. Don’t just ask your doctor whether he thinks you’re “disabled.” If your doctor is not willing to help with your case, find a doctor who is willing to help.
Third-party reports from friends and family members can also prove useful, although they should focus on their first-hand observations, not on their opinions about your medical issues or whether or not you’re disabled. For instance, if your spouse has to help you get in and out of the car and the shower, he or she should include that detail in a letter to the insurance company.
Finally, keep in mind that your insurer’s definition of “disability” can make a big difference in your case. Some policies define disability as an inability to perform any occupation, while others state you’re disabled if you can’t go back to your own occupation. Check your policy’s summary plan description, or even better, the plan document itself for specific information on your plan.
When to Get an Attorney in an LTD Case
The general rule is: the earlier, the better. Insurance companies will not hesitate to use your unfamiliarity with the process against you. One missed deadline will stop your claim in its tracks. Having an experienced ERISA attorney on your side vastly improves your chances of success. He or she will better understand how to craft a persuasive appeal letter to the insurance company and what kind of medical evidence you need to submit. Your lawyer will also be more familiar with doctors and specialists in your area who can potentially help with your case.
When your application for disability benefits has been denied, don’t give up hope. You can take steps to appeal the decision and receive the disability benefits you need to carry on with your life. You just need to do your research and do things a little differently now.
Appealing the denial
Many applicants simply give up after receiving a notice of denial from their insurance company or agency. If your application is turned down, don’t give up. It’s also never a good idea to just rush and reapply for benefits. It’s important to pursue the appeal process in the right way and obtain the necessary medical evidence to support your claim.
The appeal process involves filing a request for reconsideration. You may add new or different information to support your case and help prove to the examiners that your condition is severe and disabling. Having an exceptional long-term disability lawyer makes all the difference during the appeal process.
A lawyer will review the facts to prove your disability and help get the claim approved. Lawyers work with their clients to gather enough evidence to prove they meet the legal tests for disability under their policy wording. Should the case go to hearing, it will involve a medical expert who will advise the court regarding the claimant’s injuries and limitations working. You may also bring lay witnesses to testify regarding your disability.
What level of disability qualifies you for long-term disability benefits?
Generally, you may qualify for long term disability benefits if you are no longer able to perform all or substantially all of the elements of your current job. Although this may be entirely dependent on your long term disability policy, most policy terms indicate that to qualify for benefits, you will have to prove that you cannot do your job as well as other jobs that you may have been qualified to do based on your education, training, and experience before the condition. That’s why it’s important to review your long-term disability policy and understand the terms and conditions that apply to you in the event of a disability.
What types of conditions qualify for long-term disability benefits?
Most insurance policies will cover for any type of injury or illness that prevents the policyholder from working. However, there are certain illnesses or injuries that may be excluded in your policy because they are covered in other areas such as in your work insurance policy. A long-term disability lawyer can advise on whether the type of disability you have qualifies for benefits.
Did your claim include the necessary information?
Most disability claims are denied because they lack the correct or adequate information needed to prove the severity of the applicant’s condition. It is really important to gather strong, convincing and relevant evidence prior to filing a claim. Evidence that shows the severity of your injuries as well as crucial details regarding your work history, functional impairments and limitations and the kind of job you were able to do, can go a long way in supporting your claim.
There are different forms of evidence necessary for long-term disability claims:
Medical records: You’ll need to include detailed medical records that show how/when the condition was diagnosed, the treatment given as well as the long-term prognosis.
Employment history: The examiner may review the work you’ve done over the years. Provide a detailed summary of your work history and income and earning capacity.
Information about your job: It’s equally important to outline your job description which helps the examiners to understand the nature of your work and whether you’ll be able to carry out similar duties with your condition. Include the tasks involved in your day-to-day work as provided by your supervisor or employer, education and training.
If your claim was denied, it could be due to inadequate information. Speak to a disability lawyer who will help you determine the necessary information that lacked in your initial claim. A lawyer will evaluate your initial claim and determine its shortcomings then move forward to build a stronger appeal to increase the chances of being approved.
Are you a victim of unfair treatment?
Some applicants are denied claims unfairly. Do not assume that the examiners were correct when denying your claim. There are cases of unfair treatment by insurance companies. Keep in mind that most insurance agencies are in the business of making money and hence may try to mitigate losses by denying as many claims as possible.
Before giving your insurance adjuster any information, be aware that their top concern is to protect the insurance company’s bottom line. Therefore, it shouldn’t come as a surprise if the insurer employs deceptive or unfair tactics to minimize or deny your claim.
Common incidences of unfair treatment involve:
- When the insurer doesn’t disclose the terms of the policy
- When the policy is terminated without notice or cause
- When the policy guidelines are changed such as the disability requirements
- When the insurer claims that you fail to meet the policy standards for disability
If you suspect that your claim was denied unfairly, take the next steps with caution. Do not submit further information to the insurance company or any representatives without a lawyer. Record all communication with the insurance company and work with your lawyer to advance a strong appeal.
You may also request for a verbal explanation as to why your benefits were denied. Make sure you also get the decision in writing. Your disability lawyer will then assess the details of your claim as well as the explanation given by your insurer to determine if you have a case.
It’s your right to hire a long-term disability lawyer
Working with a lawyer to help you with your claim is always recommended. Although you are not obligated to retain a lawyer, their invaluable advice can help increase your chances of approval. Find a lawyer with extensive experience handling cases that are similar to your own.