Many people file claims for short-term disability insurance benefits and receive a denial. Getting a denial can be extremely difficult when you know you cannot work for some time due to a disabling condition. But did you know you can appeal the denial and continue seeking short-term disability benefits?
The first step you should take is to consult a disability lawyer who can assess your options for an appeal.
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A Disability Claim Denial Can Leave You Devastated
Short-term disability insurance provides benefits to individuals who cannot work due to an illness or injury. These benefits can cover the individual’s living expenses during the period of disability. When a claim for short-term disability gets denied, it can leave the individual in a very difficult financial situation.
There are many reasons why a short-term disability claim may result in a denial. Whatever the reason, however, it can be a crushing blow to the individual who is relying on these benefits to cover their living expenses. This denial is in addition to the severe medical issues they are already experiencing.
The denial of a short-term disability claim can lead to financial hardship and stress for the individual and their family. They may struggle to pay for essential expenses such as rent, utilities, and food without the benefit payments. This can lead to a domino effect of other financial problems, such as missed payments, debt, and damaged credit.
In addition to the financial strain, the denial of a short-term disability claim can also take an emotional toll. The individual may feel frustrated, overwhelmed, and helpless. They may feel like the insurance company is not taking their health problems seriously or is treating them unfairly.
Individuals who receive a short-term disability claim denial should always understand their rights and options. Most people can appeal the decision and should seek legal advice to help them navigate the appeal process. For many policies, the law sets out strict guidelines for appeals that you must follow.
You should also take care of your emotional and mental health during this challenging time. You are in no position to handle a complex appeal; leave that to a disability appeals attorney.
Common Reasons for Short-Term Disability Denials
A successful short-term disability claim can bring many benefits for you and your family, but a denial only seems to cause more problems. When you receive a denial, have a trusted lawyer review the denial letter immediately.
Below are some common reasons for short-term disability denials.
Pre-Existing Condition
One of the most common reasons for a short-term disability claim denial is due to a pre-existing condition. If an individual has a medical condition that existed before they enrolled in the policy, the policy’s terms might not cover it. To avoid this, individuals should ensure they understand their policy’s terms and coverage before enrolling.
Further, even if your condition does not qualify for benefits, there is a possibility that the symptoms of your condition might. If you are experiencing new symptoms that prevent you from working, it might be enough to appeal your claim denial from this approach.
Incomplete or Inaccurate Information
Another common reason for a short-term disability claim denial is providing incomplete or inaccurate information on the claim form. The insurance company may reject the claim if important details are missing, such as the date of injury or illness, medical treatment, or employment information. Therefore, always seek legal help to ensure you provide all necessary information when submitting a claim.
Lack of Medical Records of Your Disability
The success of a short-term disability claim often depends on the quality and quantity of medical evidence. The insurance company will evaluate the medical evidence to determine if you meet the definition of disability according to the policy’s terms. If the medical evidence is insufficient or does not support the claim, the insurance company may deny your claim.
Failure to Meet Eligibility Requirements
Short-term disability insurance policies have specific eligibility requirements you must meet to receive benefits. For instance, some policies may require individuals to have worked for a minimum period before becoming eligible. If an individual does not meet the eligibility requirements, they might get a denial.
Delayed or Late Filing
Insurance companies often require short-term disability claims to begin within a specific timeframe. If an individual misses the filing deadline, their entire claim might end in denial. Ensure you meet all deadlines when filing a short-term disability claim.
Failure to Follow Medical Treatment
You might receive a denial if you fail to follow any prescribed medical treatment. Insurance companies expect you to follow your doctor’s recommendations to the best of your ability to promote recovery and return to work. If you do not comply with treatment recommendations, the insurer might interpret it as a lack of effort to return to work.
Fraud
Fraud is a rarer but serious reason for a short-term disability claim denial. Insurance companies take fraud very seriously and have measures in place to detect and prevent it. If someone provides false or misleading information or exaggerates their medical condition, they risk a claim denial and potential action against them by the insurer.
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Appealing a Short-Term Disability Denial Under ERISA
The Employee Retirement Income Security Act (ERISA) is a federal law that regulates employee benefit plans, including short-term disability insurance policies. ERISA provides specific guidelines for the appeals process when a short-term disability claim gets denied.
Under ERISA, an individual who has had their short-term disability claim denied has the right to appeal the decision. The insurance company must provide the individual with a written explanation for the denial and inform them of their right to appeal. They must file the appeal within a specific timeframe, usually within 180 days of receiving the denial letter.
When filing an appeal, the claimant must provide new or additional evidence to support their claim. This evidence can include medical records, reports from treating physicians, or testimony from medical experts. You need to provide sufficient evidence to demonstrate that you meet the definition of disability according to the policy’s terms.
The insurance company must review the appeal and decide within a specific timeframe, usually within 45 days. However, if the insurance company needs additional time to review the appeal, they can request an extension of up to 45 additional days. If the appeal remains denied, the individual has the right to file a lawsuit in federal court.
One of the most important aspects of ERISA is that it provides individuals with protections and standards for the appeals process. ERISA requires insurance companies to follow specific procedures when reviewing and deciding on an appeal. It also requires the insurance company to provide the individual with access to their claim file, which includes all the information and documents the insurance company used to make their decision.
While this might sound like the law protects you, think again. While providing so many protections, ERISA also makes it significantly more challenging to appeal than you might ever imagine.
Another significant aspect of ERISA is that it allows individuals to seek legal assistance when filing an appeal or lawsuit. ERISA short-term disability attorneys can help you understand your rights and options, gather and present evidence to support your claim, and represent you in court.
ERISA also has specific requirements for the insurance company’s decision-making process. ERISA requires insurance companies to make decisions based on the terms of the policy and to provide a written explanation of their decision that includes the specific reasons for the denial. The explanation must also inform the individual of their right to appeal and the specific timeframe for filing an appeal.
Never begin the appeal process without legal representation. However, time is short, as there are strict deadlines to file your appeal. Begin working with an attorney immediately after you receive your denial letter.
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Building a Complete File With the Insurance Company
One rule ERISA sets out is that you must build a complete appeal file with the insurance company. If the insurer upholds the denial and you must file a lawsuit, the court can only review what the insurance company already has. Your disability lawyer can help ensure you create a claim file with the insurance company with all the necessary information to support your disability and eligibility for benefits.
Evidence in your claim file can include medical records, reports from treating physicians, and testimony from medical experts. Even if you believe you provided adequate evidence at first, an attorney can identify and fill in gaps in your file.
Below are some key types of evidence to consider when filing a short-term disability insurance claim.
Medical Records
Medical records are one of the most crucial pieces of evidence when filing a short-term disability claim. They provide objective evidence of the individual’s medical condition, treatment, and prognosis. Medical records can include doctor’s notes, lab results, imaging studies, and prescriptions.
Treating Physician’s Opinion
A treating physician’s opinion can be highly persuasive in supporting a short-term disability claim. The physician can provide detailed information on the individual’s medical condition, treatment plan, and prognosis. They can also explain how the individual’s condition impacts their ability to work and perform daily activities.
Independent Medical Examination
An independent medical examination (IME) is an evaluation by a physician not involved in the individual’s care. An IME can provide objective evidence of the individual’s medical condition and can be used to challenge the insurance company’s decision if the claim gets denied.
Testimony from Medical Experts
Testimony from medical experts can be persuasive evidence in supporting a short-term disability claim. Medical experts can provide objective evidence of the individual’s medical condition and explain how it impacts their ability to work and perform daily activities.
Work Restrictions
Work restrictions from a treating physician can serve as evidence in a short-term disability claim. Work restrictions limit the individual’s ability to perform certain job duties and can demonstrate how the individual’s medical condition impacts their ability to work.
Personal Statements
Personal statements from the individual can provide subjective evidence of their medical condition and how it impacts their ability to work and perform daily activities. Personal statements can be useful in demonstrating the individual’s pain, suffering, and limitations.
Your lawyer can gather as much evidence as possible to support your short-term disability claim. The evidence should be well-organized, easy to understand, and comprehensive. When submitting evidence, they can provide detailed explanations of how the evidence supports your disability claim.
Pursuing an Appeal in Federal Court
J. Price McNamara – Attorney for Disability Insurance Claims in Baton Rouge
You may file an ERISA disability appeal in federal court if you exhaust all other avenues of appeal with your disability insurance company. To file an appeal in federal court, you must first file an administrative appeal with your insurance company, build a claim file, and receive a final denial letter.
You must then file a lawsuit in the appropriate federal district court within a specific timeframe, usually within 180 days of receiving the final denial letter. The lawsuit must name your insurance company as the defendant and provide a detailed explanation of why you believe the insurer wrongfully denied your claim.
Once your attorney files the lawsuit, the insurance company will have an opportunity to respond and provide a defense. The court will then review the evidence presented by both parties and make a decision based on the terms of the policy and applicable law.
Pursuing an ERISA short-term disability appeal in federal court can be a complex and time-consuming process. You need an experienced ERISA attorney to guide you through the litigation procedures and advocate for your rights. An attorney can help you gather and present evidence, prepare and file legal documents, and represent you in court.
A short-term disability appeal is a complex and time-consuming process that requires the assistance of an experienced attorney in ERISA. Act now, so you have the best chance of reversing your denial and receiving the short-term benefits you need.
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