You file a long-term disability claim, and when you get a response letter, you see a denial. Many claimants think this is the end and that they have no other options. The good news is you do have options under federal ERISA protections. The law allows you to file an appeal for long-term disability benefit denials and, upon a secondary denial, file an ERISA lawsuit.
Do not search for a sample long-term disability letter online; instead, speak with a local long-term disability lawyer who can adequately file an appeal on your behalf. The problem with online sample letters is that most do not include the necessary information you need for a successful appeal. Additionally, they are boilerplate samples and do not address your specific circumstances.
Most importantly, the appeal process for disability denials requires much more than simply filling out a form. You need to create a complete record for the insurance company to review, as this sets the stage for an appeal in court if necessary.
Never rely on internet forms. Always seek help from a disability appeals attorney immediately.
Before writing the letter
There are many actions you must take before writing an appeal letter. Skipping even one step can result in another denial. The first step is understanding why you receive a denial in the first place. Have your lawyer review the denial letter and determine how much time you have to file an appeal and if there are one or more causes for denial. Some reasons you can receive a denial are missing medical evidence, not meeting the policy definition of disability, or missing a deadline.
After reviewing your denial letter, your lawyer needs to request your claim file, which includes all of the information and documentation that the insurer used to determine you were ineligible for disability benefits.
If the insurance policy has ERISA protections, there is every right to request and obtain a free copy of your file. You must send the file request directly to the insurer via fax or certified mail, list claim numbers, and keep a copy for your records. Review your claim file with an ERISA lawyer to determine if information is missing and the proper strategy for an appeal.
Your attorney can conduct legal research about your claim. They can also look for decisions from other agencies regarding your same disability. They can submit such determinations and research with your appeal letter to demonstrate that you should get the same determination.
Your lawyer can also request a copy of your long-term disability insurance policy. If you have an employer-sponsored policy, you can contact human resources, who will provide the policy to you, even if you are a former employee. Conversely, if you have an independent policy, you must request LTD information from your agent or the insurance company. Your attorney can review the language of the policy to determine a strategy to fight the denial of benefits.
Preparing an appeal
Before filing an appeal, a long-term disability lawyer will need to review everything you have already submitted to the insurer. Suppose you were not working with a long-term disability lawyer from the inception of your claim. In that case, they will need to look at every element of your claim and reverse engineer to determine what evidence you need to provide to reverse the insurance company’s decision.
Once an attorney knows what they need for your appeal, they can request the necessary documents and evidence to address the reasons in the denial letter. Individual doctor’s statements can benefit your claim, and if you are seeing multiple doctors, they might all need to provide a letter explaining their services and your medical condition.
You might also need to provide a sworn statement, also known as an affidavit. You must detail your restrictions and limitations and why you cannot perform your job duties. Every denial reason in the letter must be addressed independently with substantial evidence to ensure they do not deny your appeal.
A sample letter online is typically one or two pages, but when you work with a long-term disability appeals lawyer, you will see appeal letters that are much longer and more thorough. There might be medical condition summaries, opinion evidence, and legal arguments within the appeal. The additional pages and work that go into an appeal mean you have a better chance of reversing the denial and avoiding a lawsuit.
What you need in a disability appeal letter
There are various elements you need to include in your appeal letter. First, everything must be in writing and have a clear intent. You will need to include why you disagree with the insurance company’s decision and what evidence you have to influence that decision. The appeal letter is solely a cover letter to open up what can be a lengthy defense.
You need to include all information in your initial appeal because you cannot provide additional information once your appeal file is closed with the insurer. If you need to later file an ERISA lawsuit, the judge will only review your claim file; they will not accept new evidence.
Your lawyer will send the appeal to the insurer securely and in a trackable manner. There are deadlines to consider, and if the appeal packet is lost in the mail, you can become ineligible for benefits on a technicality.
The most important evidence you must submit is medical records and documentation. When reviewing your claim file, it is important to determine if any medical documents are missing. If there are missing records, that can be the cause of denial and might be the determining factor in reversing the wrongful denial of benefits.
Doctors’ statements can come in two forms: a narrative statement or a Residual Functional Capacity form. You will need to ask your doctor to explain your disabling condition in writing and how it impairs your ability to work. You might need to speak to specialists and others who have offered you treatment through the duration of your disability.
Side effects of treatment are also relevant to your disability claim. Some treatments have severe side effects that impair you further. Medications meant to help your ailment also have side effects that can leave you unable to drive or operate machinery. Some medicines cause extreme drowsiness, and you will be asleep more hours of the day than usual. If you cannot stay awake, you cannot drive or work. Your doctor can vouch and say you are experiencing side effects, but you should also provide a first-hand account of these adverse side effects.
The more medical evidence you submit, the stronger your claim. A generic form rarely shows your entire medical picture, but a detailed appeal file can. Your lawyer will guide you through obtaining all possible evidence of your medical state.
While your medical condition and the doctors who treat you are vital to your claim, there is non-medical evidence you can gather that will also help your appeal. You can obtain statements from friends, family, coworkers, and non-medical professionals who see the difference your disability has made in your life.
Obtaining written support from your employer is instrumental in an appeal but not always feasible since some employers do not want to get involved. If they are unwilling to provide a written statement, they can provide performance reports and your personal file to include in your appeal. Again, follow your lawyer’s advice on non-medical evidence to include.
Since long-term disability provides income replacement funds, it is contingent on your ability to work. To further help your appeal, you can undergo a professional vocational assessment. The insurance company can request a vocational evaluation, but your lawyer can also.
The insurer’s expert is supposed to be impartial, but they rarely are. Since the insurance company is paying them, they will likely help the insurance company deny a claim regardless of how your injury affects your daily life.
Dos and Don’ts of disability appeals
DO make sure you submit an appeal before the deadline because you lose your right to an appeal once it passes. Start as soon as you receive your denial letter since it can take time to collect all relevant documents.
ERISA protection offers 180 days from the denial to file an appeal.
- DO work with an ERISA disability lawyer because they handle appeals daily. They also work with insurance companies and are familiar with how they come to their determinations and how they work on appeals.
- DO submit a comprehensive appeal, which means it includes as much supporting documentation and evidence as possible.
- DO request proof of receipt for all documents you submit to the insurance company. The insurance company might claim it did not receive documents from you, and if there is no proof of receipt, you might not meet your deadline. An ERISA disability claim lawyer will send appeal letters that require signatures or other tracking information.
- DO know the insurer will watch you with the help of a private investigator. They might also send you to an independent medical examination. While the doctor will examine you, watch for anyone following you the day before or after the IME. Stay home for those few days and curtail your activities.
- DON’T submit an immediate appeal; take your time and collect all relevant evidence with the right legal help. Emotions are running high, and you want your benefits immediately, but filing a rushed appeal using online forms can hinder you from getting the benefits you need. Take your time but be aware of deadlines.
- DON’T attend an IME alone because the doctor can misrepresent their findings. Have another person with you so if there are any inaccuracies, they can be a witness.
- DON’T use a sample long-term disability appeal letter you find online. This will not put you on the right path to overturning a denial and receiving benefits.
When to contact a long-term disability lawyer
When you receive a denial, you need legal help if you have not hired a lawyer already. When you file an appeal, you do so to the same party that submitted the initial denial. There is no neutral party taking a second look. While you can provide substantial evidence and work with a long-term disability lawyer, it may not be enough to overturn the decision. Appeals can be successful, especially with an attorney on your side. If an appeal is unsuccessful, you can file an ERISA lawsuit.
When you file a lawsuit, an independent party will review the claim file and determine whether to uphold the insurer’s decisions or reverse them. However, the judge will not accept or review new evidence, so you must submit all relevant information during the initial appeal because you will not have another chance. Always work with an ERISA lawyer for disability claims.
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 J. Price McNamara ERISA Insurance Claim Attorney, 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