When you have filed for disability benefits, and the insurance company has denied your claim, you must begin the appeals process. You are understandably worried about when you can collect your money if you finally win your appeal.
The appeals process can take quite a bit of time from start to finish, and you should prepare yourself for a long and challenging process. However, you absolutely must go through this if you want to receive the benefits you deserve under the terms of your disability insurance policy.
Seek the right legal assistance and representation if you receive a claim denial. You want an experienced ERISA disability attorney handling this complex process.
ERISA Gives an Edge to the Insurance Company
There is little for insurance companies to fear when they do what they can to make your life more difficult. ERISA seemingly allows the insurance company to set the rules of the game.
However, the law does not give the insurance company the final say over your benefits, and they must follow an entire appeals process before they decide on your claim. The first steps begin with the insurance company, but you can have your day in court, where a federal judge or a panel of judges make the final decision.
First, you must comply with all the procedural rules of ERISA, although you may need help knowing the steps you need to take and the appropriate time frame. Thus, hire an attorney as soon as possible, preferably before you even file your initial claim. Getting legal help can mean the difference between an approved claim and having to go through the entire legal process.
You may immediately need the benefits that your long-term disability provides, but you cannot rush the process. The best way to keep your appeal on track is by having a skilled attorney on board immediately.
Shorter Timeframes Give You an Imperative to Act
However, the accelerated time frame is also a double-edged sword, and you must prepare to act far quicker than you otherwise may want. You need to take legal action, and time is of the essence. If you wait too long, you can lose the right to appeal your claim denial entirely.
The first deadline you must meet is filing the initial claim. Your policy will tell you how long you have to file the claim, and most policies will require you to file a Notice of Claim within 30 days of the date of disability. You must check the language of your policy closely because you might accidentally deny yourself the chance to apply for benefits if you do not know the deadline.
The insurance company will send you forms to file the claim once you send them the Notice of Claim. You must wait for an elimination period before you can even submit a Proof of Claim, and you usually have 90 days from the end of the Elimination Period to file the Proof of Claim. Otherwise, the insurance company will consider your claim submission late, and you may face long odds to get your benefits approved.
The insurance company will review your Proof of Claim, and they will make an initial determination as to whether you are eligible for benefits. They are verifying if you meet the policy’s definition of disability. Initially, being disabled means that you cannot perform the duties of your job (although the definition generally changes after two years of receiving benefits).
What Happens Once You File Your Claim?
After you have filed your claim, the insurance company has 45 days to respond with a decision. This timeframe is relatively accelerated, and the insurance company rarely decides to grant your benefits within this initial period.
If they approve your claim, it can result in them paying $1 million or more over the life of your claim, depending on what you earned before your disability.
The process grows more complex and difficult when the insurance company denies your initial claim. They must give you the reason for the denial and anything they relied on to reach their decision.
You have a lot to do with this information in a short period of time. Therefore, you must hire an experienced ERISA lawyer to help guide you through this process.
You Have to Appeal a Denial to Get Benefits
ERISA puts the onus on you to appeal the denial. The first deadline is the one you face to file the appeal and present new evidence of disability. Under ERISA, you have 180 days from the time of your claim denial to file the appeal.
During this time, you are adding documentation to your claim with additional evidence of your disability. You will respond to the specific concerns the insurance company expresses with medical records and evidence proving that you meet your policy’s definition of disability.
You must build a substantial appeal file because this is the only chance you will have to construct the record you will use at all stages of your appeal. Once you file the appeal, you can only add additional information under limited circumstances. An experienced ERISA lawyer can ensure that you have all of the documentation necessary to file a strong appeal.
Take as much time as the law allows to build the most detailed record possible. As much as you need the money, you should not file the appeal until you add all the necessary evidence. Rushing the appeal can harm your case, so do not instantly respond to the insurance company.
The Insurance Company Gets First Crack at Reviewing Your Case
Unfortunately, you do not necessarily get an objective review of the initial decision. The law allows the insurance company to have the first chance to review your claim, and they supposedly assign a different department to review your previously rejected claim.
However, you cannot expect an objective review of your claim because they do not check it with an eye toward giving you a fair shake. Instead, insurance companies design the process to cover themselves and improve their chances of winning the case in court.
The insurance company has 45 days to review your appeal and give you a decision. They can take an extra 45 days if needed, so long as there are special circumstances, but they cannot get an extension simply because they have not done their job in time. Still, it can take up to 90 days for the insurance company to give you an answer.
You Can Appeal Further When the Insurance Company Sides Against You
Assuming that the answer you receive from the insurance company is more reasons why they will not pay you what you deserve, you have another deadline to reach the next stage of the appeals process. Your policy may include its own statute of limitations for you to take the case to federal court, which you must know.
The next step is a litigation process that takes place in federal district court. A federal judge will review the same appeal file the insurance company looked at when making their decision.
The judge may ask for briefs in the case outlining each side’s position, but they will not question you under oath because you cannot add any more evidence not already in the appeals file. ERISA disability litigation intends a more streamlined process, allowing the judge to make a quicker decision.
You Can Go to an Appeals Court if You Still Have Not Won
The judge will draft a decision that decides your appeal. If you still have not won at this point, you can go to a federal appeals court, where your lawyer will explain why the federal district court judge made an error of law in reaching their decision.
Similarly, the insurance company may go to the appeals court when the district judge has ruled in your favor. The appeals court will then make what is most often the final ruling in your case. While you have the legal right to appeal to the United States Supreme Court, it is extremely rare for them to take a case unless they are trying to resolve a critical legal issue or a split among circuits.
The Timing of Each Appeal Depends on the Facts and Circumstances
It is difficult to give an exact timeframe for how long your appeal will take because much depends on whether you win at each stage. You should prepare to have patience and wait out the process, as it is worth it to receive the benefits you deserve for your disability.
Insurance companies often have an incentive to fight you to the bitter end because they do not want courts to set a negative precedent that can cost them money in the future. On the other hand, your attorney will not stop fighting for your best interests if you have a valid claim.
Do not focus on the time your appeal will take. Instead, allow your ERISA disability attorney to do their job and take the necessary steps to protect your rights under your policy and the law.
You Need an Experienced Lawyer for Your ERISA Case
While much is uncertain in ERISA litigation, there is one absolute certainty – you need an experienced ERISA lawyer to present the strongest possible arguments in an appeal.
Insurance companies have teams of lawyers whose job is to protect their interests, and they will certainly not knuckle under to an individual claimant. They may only budge if they see that you have presented a strong case. Similarly, federal judges need to see detailed and thorough claims with substantial evidence if you want them to rule in your favor.
Here is what an experienced ERISA lawyer can do for your case:
- Represent you at the claims stage, allowing you to present a compelling initial file that can allow you to receive benefits without a denial.
- Assess the insurance company’s reasons for denying your claim and determine whether their arguments have any holes.
- Work with you on documenting your file to address any reasons why the insurance company denied your claim.
- Prepare the appeal to file with the insurance company.
- Take the case to federal court and prepare the arguments for the judge to consider.
You will only receive compensation if you skillfully fight back when the insurance company or a judge has denied your claim. It does not cost you anything upfront to hire an ERISA attorney, and they will work with you on a contingency basis, receiving no pay unless you win. You must hire an experienced ERISA attorney to get the settlement you deserve.
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