Your claim for long-term disability benefits under ERISA is far from guaranteed. While you have rights under the law, you also need to deal with an insurance company that will deny claims whenever it can. As a result, you should focus closely on your claim, taking the time to make sure to do everything right.
One way to make as strong of a case as possible is to hire an attorney to advise you during the process. Although you have the right to appeal a denial of benefits, the best thing is to not get in that position in the first place. Here are 11 steps that you can take to further your claim when you apply for long term disability benefits.
Review Your Plan Document
While ERISA has rules for how the insurance company must consider your claim, each plan may differ. It could have different definitions and rules for filing the claim. Each insurance company may have varying forms and ways that they want to see the information. You must closely follow what the insurance company wants because it could make a difference in your claim. The most important definition is the one that your plan gives for the word “disability.”
Closely reviewing the policy and plan document could also give you a roadmap to preparing your claim, and it can help you stay organized. You should always know and understand the process at the very beginning. The first step should always be reviewing the actual policy. If you do not have a copy of this already, you can ask for it from your employer. If you cannot understand the terms of the policy, you may need legal help from someone who does and can help you with the process.
Give Your Employer Notification
One of the requirements for an ERISA claim is that you have given your employer notice that you cannot return to work. You should also tell them that you intend to file a claim for disability benefits. One of the possible required pieces of documentation is an employer statement. This is why they need notice of your claim ahead of time.
Get a Detailed Diagnosis
The main basis for your ERISA disability claim is the fact that you cannot work in your profession and continue to earn a living. Ultimately, this is evidenced by what your physician puts down in writing about your condition. Your diagnosis and prognosis should be very clear, and it should leave no doubt about your condition. The insurance company is not going to give you the benefit of the doubt, nor will it draw any inferences in your favor in reviewing your diagnosis.
Before filing your claim, you should visit as many physicians as you need as many times as necessary to obtain a comprehensive diagnosis. You should include this in the paperwork that you submit to the insurance company. This must go far beyond just a description of your symptoms. It is not enough for you to say that you are disabled when you submit a claim. Instead, you must prove it. In addition, you will need to sign a release that gives the insurance company access to your medical records to evaluate. These records should be thorough and document your condition.
You should pay close attention to whom you select as a doctor to write the necessary physician’s statement. Preferably, you should work with a physician with experience in diagnosing people with long-term conditions. This is important when they describe your condition. The doctor should know how to properly document your condition in a way that the insurance company will understand. A sparsely documented diagnosis will cause the insurance company to ask more questions.
Finally, your medical file should include more than just the physician’s opinion. Insurance companies are increasingly taking a “prove it” attitude towards disability claims. They want to see objective evidence that backs up your claim.
This could include:
- CT scans
- Blood panel tests
The insurance company wants something that they can look at on paper to verify what your doctor is saying. Hopefully, your health insurance will cover these tests. Even if they do not, these may be things that you need to receive long-term disability insurance.
Document Your Condition
The basis for long-term disability is that you have limitations that prevent you from working. If you find that you have any physical limitations, you should document them in a journal. This could be available to use as evidence for your claim. It can also help you if the insurance company questions whether you are really disabled. Keep notes about your condition in an organized log, and make sure to have it easily available. If you miss out on certain things or find that you cannot do something else that you previously enjoyed, make sure to write it down.
Know Who You Are Dealing With
You should almost think of the disability claims process as an adversarial one from the start. This is because the insurance company has a great deal of power over your claim since they decide whether to grant benefits (although they do not have the final say over the matter). The insurance company’s interests are not the same as yours. They look after their own bottom line, and paying claims reduces their profits. You can assume that they will be looking for reasons to deny your claim and make things harder on you.
Although you can sue insurance companies for not following ERISA rules, it is difficult to file a lawsuit over them denying your claim because the law protects them almost more than it protects you. Therefore, you can assume that you will not get the benefit of the doubt from them. This is why you need to double your efforts to get your paperwork and documentation exactly right before you file it. This could mean the difference between the insurance company granting benefits and needing to appeal a denial. The rule of thumb in every long-term disability claim is that the insurance company is not your friend.
Follow the Insurance Company’s Instructions
Insurance companies increasingly require claimants to see “independent” doctors for evaluations. While your own doctor has diagnosed you, the insurance company may want confirmation or for you to see someone else. They may have the right to do that as part of the claims process. While it may feel like a hassle, you may need to take this step if the insurance company asks. This happens at the insurance company’s expense.
Follow all of these steps and give honest answers about your symptoms and medical conditions. Otherwise, this could give the insurance company grounds to deny benefits.
Don’t, however, fall into the traps that these “independent” doctors may set for you. Remember, these doctors work for the insurance company, not you. Their job is to protect company profits, not to honestly diagnose your condition. Often they lack the training or qualifications necessary to evaluate your condition.
Make sure you talk to an long term disability lawyer before the appointment. An experienced ERISA lawyer can prepare you for the exam so you don’t sabotage your claim.
Learn Why the Insurance Company Might Deny Your Claim
One of the best ways to increase your chances of success is to understand the grounds on which the insurance company may rely in denying your claim. This will help you focus on what you need to include in your claim and mistakes to avoid that may sink your application.
Here are some common reasons why insurance companies will deny ERISA disability claims:
- They do not believe that the medical evidence supports your claim
- They do not think that your condition meets the plan’s definition of disability
- You do not have enough documentation of your condition
- Your application is missing some required paperwork
- You missed a deadline contained in your plan document
- The insurance company believes that they have evidence inconsistent with what you are saying in your claim
- The insurance company disagrees with your doctor
You can appeal a claim denial. However, the best thing is to win at the application stage. If you can anticipate why a claim may receive a denial, you can prepare your claim accordingly to hopefully avoid those pitfalls.
Complete All the Required Paperwork
You may be overwhelmed with the amount of paperwork that a long-term benefits claim asks you to complete. These are all necessary to receive benefits, and the insurance company may deny a claim if it is incomplete. There may be exhaustive questionnaires that ask you for a great deal of detail about your life and your symptoms.
You must answer all of the questions that the insurance company asks honestly. Otherwise, they may use this as a basis to deny your claim. At the same time, you should also not go overboard in giving too much information because the insurance company could base its decision on what it thinks that you can do. The key question is whether they think that you have the physical ability to work at your job.
One required piece of documentation is an employee statement. This states the basis of your claim and gives key information that the insurance company will need to evaluate your claim. This will include the exact disability that you are claiming and any secondary medical condition. While there may be a temptation to list every single possible condition, putting too many things in your claim could cause you to lose credibility with the insurance company. Make sure that your claim is focused.
Review Your Claim
Your claim must be mistake-free. You never quite know what may cause the insurance company to deny your claim. Sticklers arise during the process because the insurance company will put its interests first. For your part, you should make sure that your claim is not missing any of the required paperwork because this could hold up consideration of your claim.
You should also ensure that your claim is telling a consistent story from start to finish. Take the time to review everything in your claim and compare it against the plan document and requirements. Never submit the claim right after completing it. Instead, put it aside for a little bit and check it over multiple times. If you need outside help, have someone else review your application because a second set of eyes could catch something that you may have missed.
Get Legal Advice
At some point, you may need a lawyer’s help in the claims process. Some people will hire an attorney after they receive a claim denial, and they need to appeal. In some cases, the best time to hire an attorney is before you file the initial claim. The lawyer is familiar with the claims process and how the insurance company operates. They can help you avoid common mistakes now that could lead to a claim denial. It may make sense to invest some money upfront and have a better chance of getting the benefits that you need now. This is a process that you may not want to handle on your own.
Be Careful About What You Do
You have to assume that the insurance company is watching you throughout the long-term disability application process. This is not a matter of paranoia. It is a matter of fact. These companies will do anything that they can to avoid paying claims because it costs them money. If they can find a reason to reject your claim, they will. This includes hiring investigators to watch you, physically and online, while your application is pending.
The insurance company may try to catch you doing something that would be inconsistent with what you have said in your claim or doctor’s orders. This could include monitoring your social media to see what activities you are posting about. Be very careful with the privacy settings on your social media. The best practice is to post very little at all when your claim is in front of the insurance company. In addition, you should be very careful about what activities you do during this time.
Act like someone is following you because they could very well try to gather evidence to use against you.
Should you have any further questions, don’t hesitate to reach out to a group long-term disability insurance lawyer to get answers.
Following graduation from Loyola Law School in New Orleans in 1990, Price McNamara served as a Federal Judicial Law Clerk to the Honorable John M Shaw, Chief Judge, United States District Court Western District of Louisiana.
Mr. McNamara founded the Law Offices of J. Price McNamara, and began putting his past experience to work for the injured and disabled clients he now represents against the insurance companies in personal injury and long term disability and other insurance disputes in both federal and state courts