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.
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.
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.
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.