When you get a denial letter from the insurance company telling you that you do not qualify for long-term disability benefits that you were counting on getting, you likely feel a range of emotions. The first two are likely to anger and shock.
Next, you may feel the compelling urge to fight back and do something. You may initially want to fire back at the insurance company with a letter that gives them a piece of your mind.
Do not do that.
If you want justice, contact an experienced ERISA long-term disability attorney. Do not try to handle the appeals process alone because it likely will not go well for you.
The Best Way to Write an Appeal Letter Is to Have an Experienced Lawyer Do It
Writing an appeal letter when your long-term disability claim receives a denial is not something you should attempt to do on your own. While appealing to the insurance company may seem simple, this letter is more important than you realize. If you send an incomplete appeal without crucial attachments and documentation, you will lose the right to resubmit it. This will end your ability to appeal your claim denial effectively.
When filing an insurance company appeal, you must show why your condition fits into your plan’s definition of disabled and why the insurance company was wrong to deny your claim in the first place. You are dealing with complex medical and legal concepts against an adversary that has plenty of resources at its disposal. When the insurance company says no to your claim, they have committed to a strategy to save money at your expense.
The ERISA Appeal Involves a Distinct Process
Instead of trying to write the appeal letter on your own, you should contact an experienced ERISA long-term disability attorney. The truth is that there is far more to an insurance appeal than just writing the letter. Any letter is just one part of the process explaining the evidence you will need to present along with your appeal.
Your lawyer will understand the importance of the insurance company’s appeal and why you must take it seriously. You need a lawyer who can build the case you will make throughout the appeal, no matter what court you go to for relief.
You Must Understand Why Your Claim Received a Denial and Whether There Is an Opening to Appeal
The appeal process begins with reviewing the insurance company’s reason for denying your claim. Based on recent changes to ERISA regulations, the insurance company must tell you why they denied your claim and supply you with the documents they relied on to reach their conclusion. Otherwise, they may be penalized in the appeal process.
You will review the insurance company’s documentation that underlies your claim denial. There may be holes in their reasoning, or their position may stem from a misunderstanding. You may learn that the insurance company completely ignored the opinion of your treating physician in favor of the view of a doctor who has never seen you in person.
Either way, an appeal is about more than just arguing with the insurance company. You need to present evidence that shows why you meet your plan’s definition of the word disabled or why the insurance company mishandled your claim in a way that denies you rights.
You Need to Build a File that Shows Why You Deserve Benefits
Once you review the denial reason, you should consider the additional documents you must provide to demonstrate your disability. In a sense, the insurance company has given you a roadmap for strengthening your claim at the outset of the appeals process. You may need more objective test results that prove your disability, or there may have been some gaps in explaining your existing test results.
Your lawyer will work to build an appeal file, which might include:
- The original file that you submitted with your initial claim for benefits
- Any new evidence that can strengthen your cases, such as additional CT scans, MRIs, and other test results, can objectively show your qualified disability.
- Statements from your treating doctor about your disability
- A personal impact statement
- Statements from family and friends who observe your condition
- Reports from vocational experts who are familiar with your job duties and what it takes to discharge them
- An explanation to the insurance company of why they were wrong to deny your benefits
It takes experience and skill to build the appeal record because you are trying to tailor it to how a judge may view your claim.
You Must Follow Tight Timelines
In addition, you may not know the necessary procedure and the deadlines to file your appeal. ERISA gives you a tight timeframe of 60 or 180 days to appeal your claim denial. You may not know the deadline on your own, and you might not write an effective appeal letter within that deadline.
You need to do a lot in a short time. You might need to go for more testing, and you also need to know how the results fit into the story that you are telling with your claim and appeal. This is far too much for the average person, let alone someone who does not have the legal background to understand the appeals process.
Every Step of the Appeal Makes a Difference in Your Case
There is another compelling reason you should never write an appeal letter to the insurance company on your own. You may not think much of the insurance company’s appeal, questioning why you should go to great lengths to hire a lawyer. Many people (correctly) believe that the insurance company is biased, and they should not spend much effort appealing directly to the insurance company.
ERISA puts a great deal of stock in the appeal to the insurance company, even if the initial reviewers do not take it seriously. The law dictates a unique appeals process that differs from other insurance claim appeals. If you privately purchase a policy, you can go straight to court to appeal and file a standard case for a breach of contract when you get a claim denial.
You Need an Attorney Because ERISA Appeals Are Complex Matters
ERISA will not give you the day in court that other insurance claim appeals allow. While you will still get a day in court, it will not take the same form. The insurance company appeal is a critical part of the process even if you have little faith that the company will take it seriously.
The appeal file that you build at first will be the one that stays with you throughout your case. It will be the one that a district court judge and an appeals court panel review if your initial insurance company appeal upholds the denial. You will only get one chance to build an ERISA appeal file. The law will not allow you to add to the appeal file if your case goes to court. The appeal file is locked down, and you cannot add any additional evidence to it. A judge can permit you to add evidence in limited circumstances.
You Can Harm Your Legal Prospects by Acting on Your Own
If you expect you can take the first crack at an appeal on your own and then bring a lawyer in, later on, this approach will backfire on you. In many ways, you play your cards the minute you send the appeal letter to the insurance company, and you cannot go back and fix it.
Insurance companies even won appeals when judges improperly allowed the plaintiff to supplement the file with information that was not in the initial appeal.
You should also not count on not explaining your case in person to a judge when the insurance company’s appeal upholds the denial. You will not get that chance, as ERISA appeals do not allow in-person witness testimony. You will not get to build a case at trial like you can in other lawsuits. Your lawyer will have a chance to draft a brief that explains your position and why the insurance company is wrong. However, the brief can only address evidence in the appeal file and cannot introduce anything new into the case.
The Insurance Company Often Stands Strong In Its Position
Chances are that you will not persuade the insurance company by an appeal letter that you write alone. Companies spent decades building an entire mechanism and infrastructure to handle claims. They are constantly assessing their risks when they deny claims and appeals.
If they see you operating on your own, they will see little reason to grant your appeal. If they see an experienced lawyer on the other side, they will take you more seriously, even if they did not eventually grant your appeal.
The entire ERISA system is not necessarily in your favor. That is the irony of the law. Even though ERISA should protect employee benefits, the procedure favors insurance companies. It is close to impossible to win an appeal on your own. The insurance company has a battalion of lawyers on its side whose job is to make your life more difficult.
An Attorney Gives You a Fighting Chance Against the Insurance Company
You can create a more level playing field when you contact an experienced ERISA attorney to handle the appeals process on your behalf. Our lawyers will take care of the details on your behalf, working to build you an appeal file that can persuade a federal court if the insurance company does not reconsider its previous denial of your claim.
Having a tough lawyer on your side who knows ERISA can give you a fighting chance against an insurance company that is bound and determined not to pay you the benefits that you need. They have lawyers whose job is to save money, and you need to counter them with your own fighter.
If possible, hire an attorney before submitting your claim in the first place. Your rights under your plan are crucial, and your family’s financial well-being is on the line until you can return to work if you can even work again at all.
While the facts regarding your condition do not change, an attorney can help you present them in a claim in the most persuasive light possible. Sometimes, a well-documented claim can be enough to persuade the insurance company not to deny it and force you to go through the appeals process.
Contact an Experienced ERISA Appeals Attorney Today
If you have received the dreaded claim denial from the insurance company, you do not have to let it go when they have wrongfully taken away what you deserve. The right ERISA law firm will help you fight back through the insurance company appeal and in federal court when necessary.
Contact a trusted law firm for a free case evaluation to learn more about how an attorney can help you. When you are in for a long fight, you need an experienced ERISA long-term disability attorney to spearhead your counterattack.
Too many people make mistakes early in the ERISA claims process that haunts them for the rest of the case. You might never imagine that a seemingly minor error or omission can deprive you of the benefits you need, but this is the reality of ERISA insurance coverage.
You need legal help from the beginning of the process or immediately after learning of a denial.
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 the Law Offices of J. Price McNamara, 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