As a Former Insurance Company Attorney, I’ll Tell You Their Playbook (Don’t Skip This…)
The insurance company hopes you’ll react to its claim denial, now that they’ve exhausted you, in one of two ways – call them the two paths to certain claim denial:
- You give up or delay, letting your appeal deadline expire; or
- You file an “appeal” that simply argues why the claim denial was wrong, without submitting stronger new EVIDENCE (most claimants, and attorneys unfamiliar with federal ERISA law, make this mistake).
The insurance company knows that by choosing either of those two paths, you will lose your last and best chance of getting benefits.
Paths for Claim Denial
The first path for certain claim denial: If you let your appeal deadline (usually 180 days from your receipt of the denial letter) expire, your claim is over. You have no further recourse, and cannot bring a lawsuit in court. The appeal is mandatory before filing a lawsuit, but if you miss the appeal deadline, you can no longer appeal or file a lawsuit. A huge number of claims are lost by simply waiting too long to appeal.
The second path for certain claim denial: If you “appeal” by submitting argument alone, without new, stronger EVIDENCE, the insurance company knows that ERISA law prohibits the court from considering any evidence that you didn’t submit with your appeal before filing suit. Thus, appealing in this manner is a trap. By doing so, you lock yourself out of building the strongest claim you can for good. Most claimants and attorneys unfamiliar with ERISA law don’t realize this until it’s too late. Therefore, most put little effort into the appeal process, mistakenly thinking they can get serious about building a strong court case later if the appeal is denied. You can do that in a “normal” case not falling under ERISA law, but under ERISA law, everything is different.
This ill-advised “appeal” approach, with argument alone and little or no new evidence, is often the product of waiting too long. A well-built appeal requires thought, strategy, and time as you’ll see below. Letting the deadline sneak up on you, and quickly throwing something together to meet it, is the worst possible way to approach preserving your right to years of critical financial benefits.
The tragedy is, neither your insurance policy, nor your denial letter will tell you any of this. But your insurance company knows all about it, and is happy to sit back watching as you fall into these traps.
If fact, they’ll even lead disabled physician claimants down this second path for certain claim denial. I can’t tell you how many times clients have told me, “After the initial claim denial, the insurance adjuster called, was really friendly, and told me not to worry. She said that initial denials are common, that I had a strong case, and I didn’t really need an attorney – all I had to do was write a quick appeal and send it in.”
Insurance adjusters who say that know exactly what they’re doing. They are not your friend in this process.
But there’s a third path. It’s what the insurance company DOESN’T want you to do, and it’s exactly what you SHOULD do for best chances of claim approval.
This third path is to BUILD your claim and appeal strategically with NEW EVIDENCE (not just ARGUMENT), using a tested and successful PROCESS that PROVES your claim the way they know has the best chance to stand up in court if they deny your appeal.
That’s what wins benefit claims– as well as appeals and lawsuits, and the years of future financial security you paid to protect. But avoiding pitfalls and getting it right is critical.
Physicians’ Disability Insurance Policies and Core Provisions: An Overview
Below is a brief but important overview of Physicians’ disability insurance coverages and important policy provisions, followed by our step-by-step Win My Benefits process to build a strong claim or appeal a denial of benefits.
We’ll cover the following:
- Short-term vs. long-term disability insurance
- The key policy provisions that drive a physician’s long-term disability claim: “Disabled,” “Disability,” and “Own Occupation” (or “Your Occupation”)
- True Own-Occupation Definition of Disabled or Disability
- Transitional Own-Occupation Definition of Disabled or Disability
- Modified Own-Occupation Definition of Disabled or Disability
- Any Occupation Definition of Disabled or Disability
- Illustrated Comparison of How the Different Common Definitions of Disability Work
The Fight: The Most Commonly Disputed Issues in a Physician’s Disability Insurance Claim Denial with Examples
- The common issues in the physician’s disability claim dispute
- Examples of typical physician’s disability claim dispute fact scenarios
- Our emergency room physician client’s recent dispute with Prudential is a classic example
Federal ERISA Law, and its Impact on Physician Group Disability Policy Claims: a Critical Distinction with Big Consequences
- Why different laws apply to group and individual policies and why it matters
- What the insurance company hopes you don’t know about federal ERISA law until it’s too late
- What is so different about an ERISA disability insurance case?
THE CLAIM PROCESS
THE ADMINISTRATIVE APPEAL
THE FEDERAL COURT LAWSUIT…
A Step-by-Step Process for a Physician to Win an ERISA Disability Claim - Shredding the Insurance Company Playbook and Beating Them at Their Own Game
- Calendar your appeal deadline
- Analyze the insurance company’s denial letters
- Analyze the insurance company’s claim file or administrative record
- Analyze the long-term disability insurance policy, plan and summary plan description
- List the foundational information supportive of your claim
- Gather and analyze medical records to see how well they support the claim for disability and supplement where needed
- Decide what additional evidence may be helpful
- Conduct legal research
- Construct the best argument
- Final review
- Submit the best argument and await a decision