Long term disability insurance is designed to protect you against unforeseen illness or injury that may leave you unable to work. If you have filed your disability insurance claim and received an unfavorable decision, Sokolove Law may be able to help you take legal action.
Denial of your long term disability insurance claim is a setback with serious financial and emotional impacts.
Knowledge, persistence and patience are your strongest allies in fighting for and winning the compensation you may deserve. The following steps are offered as a general guide to a long term disability appeal. Keep in mind, however, that the appeals process varies somewhat among insurers, and denials are often based on technical issues rather than merit. Working with a long term disability attorney to handle your appeal or review your paperwork can help you avoid delays and costly errors.
Step 1: Understand Why Your Claim Was Denied
To notify you that your claim has been denied, your insurer must send you a letter that covers the following points:
- The specific reason(s) for the denial;
- The specific policy provision on which the determination is made;
- The information required to validate the claim;
- The steps of the appeal process;
- Your right to sue under ERISA (Employee Retirement Income Security Act); and
- Any internal rules, guidelines or criteria that entered into the claims decision.
Read the letter carefully. If the language is vague or you don’t understand something, call the claims representative and ask for an explanation. Remember, your purpose at this point is to get information, and you’ll be more likely to get it if you’re pleasant and courteous.
Depending on what you learn from the claims representative, you may want to follow up with more specific questions. For example:
If medical records regarding your condition are incomplete or missing:
- Which records does the insurer have?
- Specifically, what is missing?
- Is the insurance company looking for certain lab tests or other clinical findings?
- Was your doctor’s statement incomplete or lacking in detail?
If the insurer is questioning whether you are able to perform work described in the plan:
- What occupation is the insurer referring to?
- What job description is the insurer using?
- Does the job description accurately reflect your actual duties? Or is it a generic job description pulled from an occupational handbook?
If the insurer claims your request for benefits lacked sufficient proof about your symptoms:
- Pain and fatigue are examples of subjective symptoms that may be difficult to prove. Ask the claims representative what kind of proof they’re looking for.
If the insurer claims there was no coverage:
- Ask for the specific policy provision on which the determination was made
Step 2. Know the Deadline(s) for Your Appeal
Deadlines are critical in any legal process. Missing a deadline can have serious consequences, from frustrating delays to forfeiture of your right to appeal. The deadline for filing a long term disability appeal should be included in the insurer’s denial of claim letter.
The deadlines for appealing a denial from a group disability insurance plan provided by your employer are set forth in the federal law known as ERISA, and most (but not all) individual policies also follow ERISA rules. Under ERISA, you have 60 days to appeal the denial, and the insurer has 60 days to conduct a review, followed by another 60 days if necessary. The insurer’s review must be conducted by someone who has greater authority than the representative who originally denied the claim.
Be sure to set reminders to notify you of an approaching deadline. To avoid complications and delays, it’s best to submit your appeal as early as possible.
Step 3. Stay Focused and Document All Contact with the Insurer
Try to approach every contact with your insurer as the fact-finding mission it is. Although you may feel angry or threatened by the denial of your claim — or frustrated because you’re one person fighting a big insurance company — hostility and sarcasm won’t help.
Before you call your insurance company, take a few minutes to gather your thoughts and make some notes. It will be easier to maintain a cool head if you’re well prepared. For written communication, read your email or letter aloud in the presence of a friend or family member and ask for their input before you send the message.
Remember – you can vent your frustration with a trusted friend or your spouse, but the goal of every communication with your insurer is to move the process forward.
Step 4. Gather New Supporting Information
After talking with your long term disability claims representative, you’ll probably know what kinds of additional information you must submit to answer questions and clarify details. Following are some examples of documentation that can help support your appeal.
- Start by identifying any doctors’ statements or other medical records the insurance company is missing.
- If you haven’t been keeping a journal of your symptoms, now is a good time to start. Each day, record how you’re feeling and how your pain or fatigue affects your work. The journal can also be a valuable diagnostic and treatment-planning tool for your doctor.
- Ask family members or friends to write their observations – as specific and detailed as possible – of how your symptoms have impacted your daily life.
- If you and your insurer don’t already have one, ask your doctor to write a detailed letter explaining in medical terms why you are unable to perform your job. The letter should include specific challenges to the insurer’s denial of your claim, such as lab results or detailed progress notes.
- Ask your supervisor for copies of any notes in your personnel file that address how your symptoms have affected your work performance.
- Request a letter from your employer detailing all the duties you perform in your job. Ask your employer to specify the tasks you can’t do because of your disability.
- Ask your supervisor and coworkers to give a written account, as detailed and specific as possible, of how they saw your disability affect your performance.
Step 5. Write an Appeal Letter
After you’ve compiled your documentation, write a letter of appeal that states your case, point by point.
- Write a brief overview of your position.
- Tell how the evidence shows that you are indeed “disabled,” as defined by your insurance policy.
- List the contents of your documentation packet and explain how each document you’re submitting applies to your appeal.
- State that you are prepared to continue in the appeal process until your claim is approved.
- Avoid personal attacks, opinions, or claims you can’t support with evidence. Keep your purpose in focus to move the process forward and get your claim approved.
- Don’t make threats, serious or not. A simple cc: to your attorney and one to your state’s Department of Insurance or Insurance Commission is enough to let your insurer know you mean business.
Send the letter by overnight or certified mail with return receipt requested, and be sure to keep the proof of delivery.
Step 6. Follow Up
After a couple of weeks, call the insurer to make sure your letter was received and to ask how your appeal is progressing. This is a good time to remind the insurer that you intend to continue the appeal process until your claim is approved.
Step 7. If at First You Don’t Succeed…
If your long term disability appeal is denied, ask your insurer to consider another appeal. Then repeat the first six steps, with an emphasis on finding new information to change the insurer’s mind. If you haven’t worked with an attorney up to this point, this may be a good time to contact us for long term disability insurance denial advice.
Filing a complaint with your state’s Insurance Department while your second appeal is under review will lay the groundwork for you to file a lawsuit if your appeal is again denied. Although your insurer may not reverse the denial of your claim as a result of your complaint, you are required to exhaust all administrative remedies before you file suit — should you fail to exhaust your administrative remedies, your suit could be dismissed. If your policy was purchased individually and is not subject to ERISA, you may not be required to exhaust administrative remedies before you sue.
Step 8. Take Your Claim to Court
Even if you’ve exhausted the appeals process and your claim hasn’t been approved, don’t give up hope. Consider consulting a qualified long term disability claims attorney who can advise you on your case. If you decide to proceed, your attorney can file a suit against your insurer in an attempt to have the denial of your claim overturned.
Why Sokolove Law?
- For 30 years, Sokolove Law has helped people just like you get the legal support they need, regardless of race or income.
- Sokolove Law has helped people in all 50 states get the legal support they need to move successfully through our court system. We have helped thousands of people with their long term disability denial appeals.
- We provide a FREE case evaluation and you only pay us if you are successful in your appeal.