The insurance company has a powerful financial motivation to deny your long-term disability claim.
If they agree to pay your benefits, they will need to pay you for at least two years and can be on the hook for payments for the rest of your career, which can be more than a million dollars. They will work hard to find a reason to deny your case, and the law essentially keeps them from facing repercussions for aggressively denying claims.
You may be shocked to learn that the insurance company has denied the long-term disability benefits you were counting on. It happens far more often than you think, where the insurance company finds some justification to argue why you do not meet the requirements for showing that you are disabled. In such situations, seeking the assistance of an ERISA disability appeals attorney is crucial. Then, you must begin a process that will likely lead to litigation.
Let Your Lawyer Handle the Entire Appeal Process
Writing an appeal letter is something that you should not try to handle on your own because, in an ERISA case, the appeal is of critical importance. The law sets a process you must follow. You need to get it entirely right to win your case because what you do during the appeal carries significance in the future. If you make mistakes during the appeal, you cannot fix them later.
You Need to Appeal to the Insurance Company First
What you write in the appeal letter will usually not win you benefits because the ERISA appeals process favors insurance companies in practice. In other insurance contexts, you can take your case straight to court when the insurance company denies your claim, and you do not have to go through any internal appeals process first.
A group long-term disability claim case goes straight to a judge, who will review the evidence you obtain and present during your case.
When the insurance company denies your long-term disability claim, you must undergo an entire appeals process. The law requires that the first part of your appeals process go through the insurance company. It seems unrealistic to expect the same company that initially told you no when you applied for benefits to reverse their decision.
The Insurance Company Appeal Is a Longshot that You Must Take
Insurance companies claim they assign the appeal to a special division that had nothing to do with the initial decision. While that may be the case, imagine how long these employees will last at the insurance company if they consistently overturn denials and cost their own employer money. While a handful of insurance company appeals succeed, most do not.
Nevertheless, you must fully participate in the insurance company appeals process. ERISA intended to create a streamlined process so you can get a quick decision on any appeal, yet the actual effect is that the law causes another speed bump on the way to court.
The Appeal File Is the Crucial Part of Your Case
However, a requirement in ERISA raises the importance of the appeal file you will assemble in your case. When the insurance company initially denies your claim, they must provide you with the reason why. Seeing the grounds for denial, you can present your own evidence in the appeal that shows why you meet the policy’s definition of disabled.
While you may think the appeal letter is the most crucial part of your file, it actually carries little weight. The power is in the file you will build for the insurance company to consider, and they will make their determination based on how they see the evidence.
An effective ERISA long-term disability appeal file may consist of:
- Objective medical evidence, such as MRI test results that show the extent of your disability
- Statements and testimony from your treating doctor
- Statements from family members and friends who see your condition frequently and are aware of your limitations
- Residual functional capacity reports
- Job description evidence under the federal government’s Dictionary of Occupational Titles
- Reports from vocational experts that detail what you may or may not be capable of
Your Appeal File Could Improve Your Chances of Winning
You need to file a strong appeal file. If you have persuasive evidence that shows you are disabled, the appeal file can even stand on its own. In some cases, the appeal file may speak for you, depending on what the judge allows in your appeal. The more thorough your file, the more leverage you have as your case progresses.
The appeal file is critical to build now because ERISA locks down the file once you send it to the insurance company. If you do not win your insurance company’s appeal (which is the likeliest outcome of the case), you will need to take your case to the proper federal district court. This step is the first time you can get any objective consideration of your claim.
The Judge Will Review the File They See in Front of Them
When reviewing your case, the judge will only consider the evidence you presented to the insurance company as part of the initial appeal file. The law states that you cannot supplement this file under most circumstances, and this rule has very few exceptions.
Insurance companies often file and win their appeals when the judge wrongfully allows a plaintiff to add evidence to the administrative appeal file.
Thus, what you file as part of the insurance company appeal will essentially be the last word you have outside of any briefs that your attorney might file in your court case. They cannot add any objective testing, statements, or medical evidence.
Therefore, the insurance company appeals process really is a case of “speak now or forever hold your piece.” You cannot afford to rush the process and must take a thorough approach to present the most compelling case possible.
It does not matter whether the insurance company will side with you on your appeal, as they are not your real audience when you build an appeal file. The real audience is the federal judge, who will decide your case and give your appeal a completely objective review before reaching a decision.
These procedural limitations make it even more crucial to hire an ERISA lawyer from the moment you receive a denial letter (if not before). They can ensure you build a complete appeal file with the insurer to preserve your rights should your case make it to court.
The Judge Reviews the Decision That the Insurance Company Made
Recent legal precedent has held that federal judges review the insurance company’s decision to see if they made an error instead of taking a fresh look at your case (de novo review). For that reason, you should build the strongest appeal file possible. Judges will review the decision against the evidence in your file and overturn the denial if they see that the insurance company has wrongfully denied your claim.
If the federal district court judge does not rule in your favor, you must take your case to the appeals court for that circuit. The rule in the appeals court is the same; the judges will review the same appeal file and will not allow you to add any new evidence to the file. The appeals court checks the case to see if the district court judge made an error of law in ruling against you.
Your appeal is serious at every step of the way. The strength of your case will determine whether the insurance company can get away with denying you the benefits they owe you under the terms of your policy. This appeal can mean the difference between receiving benefits for as long as you qualify and getting nothing. It can be a seven-figure case.
Never Try to Handle an Appeal on Your Own
Refrain from trying to do any part of an appeal on your own. If you make a haphazard attempt to appeal, your record may miss crucial evidence for the rest of your case.
An ERISA lawyer can do little to help reverse the insurance company’s decision. You will then not qualify for the benefits you need, leaving you in a precarious financial position when you cannot work. Simply stated, there is little chance of beating the insurance company without the help of an attorney.
How an ERISA Attorney Can Help You
You can contact an ERISA long-term disability attorney as soon as you learn that the insurance company has denied your claim.
Your attorney will:
- Review the basis for the insurance company’s denial of your claim to understand which additional paperwork you need to submit as part of the appeal file
- Build the appeal file, including as much information and evidence as necessary to build the strongest possible case
- Communicate with the insurance company about your case in the hopes of securing benefits
- Take your case to federal district court and draft any necessary briefing on your case
Your Case Can Settle Along the Way
A settlement is one possible resolution to your case. The insurance company knows it may need to fight your case for years in court, with the chance that they may have to pay you benefits.
They pay their attorneys out of their own pocket, while your lawyer works for you on a contingency basis. The insurance company knows that a judge ruling against them can cost them money for your benefits and set a bad legal precedent for them.
Accordingly, they may settle your case. Your attorney can negotiate a settlement with the insurance company if it is in your best interest.
Alternatively, you can hire an attorney to build your initial disability claim. You do not need to wait for a denial to get legal assistance for your ERISA claim, as you can submit your strongest possible claim when you have an attorney prepare it.
Your lawyer will ensure you include complete and accurate information, along with all necessary medical evidence and documents to support your disability status. Then, you may stand a much better chance of having your benefits approved right away without having to appeal a denial.
Hindsight might be 20/20, however, and you might have already filed a claim on your own and received a denial of benefits. Do not worry that this is a final decision and you must proceed without financial support. Instead, seek immediate representation from an attorney who handles ERISA disability appeals. They can begin by crafting a thorough and persuasive appeal letter and file for the insurance company to review.
You Pay Nothing Upfront for an ERISA Lawyer
The good news is that an ERISA attorney costs you nothing to hire. Not only do you not have to pay for a consultation, but you also will not have to pay your lawyer while your case is proceeding through the appeals process.
The same thing is true whether you settle your case early or your case takes years to resolve. Your attorney only requires payment if you win your case, and then they are paid from the proceeds you receive from the insurance company.
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