Since you are reading this guide, chances are you have suffered an injury or illness, and working is now difficult or impossible. If your employer offers long term disability (LTD) benefits, or you have a private LTD policy, you should apply for benefits as soon as possible. If your long term disability policy is provided by your employer, the Employee Retirement Insurance Security Act (ERISA) applies unless you work for a church or government office.
If your ERISA long-term disability claim is denied, or if your insurer claims you can return to work and cuts off your benefits, you have the legal right to an administrative appeal. Your disability insurance company will make this sound easy, but it is a detailed process that involves persuading someone at the insurance company that the original denial was an error and the insurer should overturn it.
An experienced long term disability lawyer can explain how to appeal a long term disability denial in detail. In the meantime, review this handy guide before you schedule your free case consultation.
Your Guide to How to Appeal a Long Term Disability Denial
In this step-by-step guide, you will learn about the long term disability appeal process and how you can improve your chances of successfully appealing a cancellation or denial of long term disability benefits. You can greatly improve your chances of winning an ERISA appeal by working with a dedicated long term disability attorney who will fight for you. Here are the steps in the process that you need to follow to have a better chance of winning your appeal.
Table of Contents
- Step 1: Hire an Attorney
- Step 2: Understand the Basis for Denial for Long Term Disability
- Step 3: Review the Documentation
- Step 4: Develop a Strategy
- Step 5: Request an Appeal
- Step 6: See an Independent Doctor
- Step 7: Establish Your Job Responsibilities
- Step 8: Develop Your Factual Record
- Step 9: Wait for the Decision
- Step 10: Appeal to the Federal District Court
- The Federal Appeals Court
- Consider Consulting with a Long Term Disability Lawyer Today
If you are not already working with a lawyer, the denial of your long term disability claim is a surefire indicator that you now need one. The ERISA appeals process is complicated, and you can’t afford any missteps from the very start.
The disability insurance company closely reviews claims, and they must follow federal ERISA rules (or risk facing a lawsuit). Although you will work with the insurance company during the appeal, if your long term disability claim is denied, they become your potential opponent in future litigation. You cannot face them alone and hope to succeed.
The ERISA long-term disability appeals process is very technical. You may need to provide detailed medical evidence, testimony, and extensive documentation. Most long term disability insurance companies are more interested in protecting their profits than paying disability benefit claims. As a result, many long term disability claims are denied for a multitude of reasons. With so much at stake, appealing a long term disability denial is not something you should do on your own.
An experienced ERISA attorney knows how to deal with disability insurance companies. A tenacious long term disability lawyer might persuade the company to reverse its initial denial, or they can take the case to court. Either way, the appeals process is complex, and it requires the experience and resources of someone who has a track record of taking on insurance companies and winning.
If you are worrying about whether you can afford an attorney, stop worrying. Under a contingency fee agreement, you won’t pay any money out of your pocket for an attorney. The long term disability attorney only receives payment if you win your case.
The disability insurance company is legally obligated to explain the grounds for its denial decision.
They may deny your claim because:
- Your condition does not fit the definition of “disability” contained in the policy.
- The medical records and evidence provided with your claim did not support your contention that you have a long-term disability.
- Your application did not contain the required documentation to support long term disability benefits.
- Your application did not meet certain deadlines or follow timeliness requirements.
- The insurance company observed conduct or behavior that was inconsistent with your application. (Yes, the insurance company may employ investigators to follow and observe you or look at your social media)
After you receive a long term disability denial, you should review your claim application to see if the insurance company’s denial makes sense or if they made a mistake. Either way, you can correct the mistake or provide additional evidence during the disability appeals process. Again, do not try to appeal the denial alone, no matter how easy the insurance company tries to make you think it is. Discuss your administrative appeal with your long term disability attorney to see how you can counteract the insurer’s arguments.
There are several key documents that you should review as part of your disability denial appeal. The first is the plan documentation if you do not already have it. This will tell you what you may have missed in your application. You can also review the plan summary to ensure that the insurance company followed it when denying your claim. You should request this from the insurance company in writing. They must provide it to you upon request.
The insurance company must also provide the documents that it reviewed to reach its decision to deny your benefits claim. Recent changes to the federal rules governing ERISA long-term disability have made the decision process far more transparent. The disability insurance company must now give you the documents upon request. This is a step you should not skip. Your long term disability lawyer will ask for these documents on your behalf and review them closely.
There must be a reason for an appeal. In other words, you have to show that the insurance company was wrong. Maybe they missed a key part of your case, didn’t review an important medical document, or just reached the wrong decision. You should review your claim and the reasons for the denial closely with your long term disability lawyer. Your attorney will develop a list of arguments to use for the appeal. If possible, you should point out multiple reasons why the insurance company was wrong when it denied your disability benefits.
ERISA appeals require planning and forethought under tight deadlines. Insurance companies will need a detailed and compelling description of why they initially erred before you will have a chance to win at the initial stage of appeal.
You have to formally request an appeal when you receive a long term disability claim denial. It does not happen automatically. You ask for the appeal by sending a letter stating the reason and basis why you want the insurance company to reconsider its denial. By this point, you must have already reviewed the reasons that they provided for the denial and your claim to establish your arguments.
Your long term disability lawyer can send the appeal letter on your behalf as your authorized representative. ERISA sets strict deadlines for requesting an appeal of disability benefits. You only have 180 days after you receive notice of the denial to file an appeal letter.
The insurance company will appoint someone to review your LTD claim appeal. This is a different person than the one who initially denied your claim. The reviewer should approach your case with a neutral and fresh set of eyes. However, at the end of the day, they still work for the same disability insurance company, and they may not keep their jobs if they grant too many appeals.
It is now a routine procedure for the insurance company to send you to an independent doctor for an evaluation. They want to understand your condition on their own, and they may not accept what your doctor says without further corroboration. One of their favorite tactics is to send you to a different, “independent” doctor that they choose.
If the insurance company wants you to see this doctor, you must cooperate. They can ask you to visit the physician as many times as they want to get the information that they believe they need. If you fail to cooperate, this could be grounds for denying your benefits. Insurance companies could send you to this doctor at any part of the process. If you are appealing a long term disability denial, you can expect this as part of the process.
Remember, the key is to show that you cannot do your job, or possibly any job. Whether you receive benefits is a person-specific decision. If you have a physical job, your injuries could render you unable to work. It is important to be very precise in your appeal about what your exact job duties are. This way, you could show that your disability keeps you from performing the duties of your job. If you are vague about your responsibilities and current abilities and do not provide enough detail, you cannot trust the insurance company to fill this in to help you.
It’s important to invest a lot of effort into developing your factual record when you appeal a long term disability denial. While ERISA gives you multiple levels of appeal, it also limits your options at later stages. You have one chance to build a factual record, and that is during the insurance company denial appeal stage. Once that process is complete, you cannot add additional evidence in the future. In other words, if your case goes to court, you cannot add new evidence, and you must rely on the existing factual record to win your case.
As part of the long term disability denial appeals process, you have the right to conduct discovery. This means that you can obtain the information that the insurer used to make its decision about denying your benefits. In fact, you have the right to receive all documentation that is relevant to your claim. Federal regulations require the insurance company to provide certain documentation, and if they fail to follow these rules, you can bring legal action.
Generally, the administrative record in your ERISA appeal will include:
- The official plan document (this will allow the reviewer or a judge to understand plan requirements)
- The summary plan description
- Your initial long term disability claim that the insurer denied
- Medical records (including diagnosis and treatment notes)
- Communications between you and the plan administrator (which is why it is vital to save these)
- The denial letter (setting out the reasons for the denial)
In addition, you can obtain all of the internal insurance company documentation pertinent to the denial of your claim. These documents might show how the insurance company did not follow ERISA guidelines and made the wrong decision.
Federal regulations require the insurance company to issue a decision on your appeal within 45 days. The insurer can take 45 additional days if they need it, but they must notify you and explain why they need more time to process your appeal. The insurance company also has the right to ask you for more information during your appeal. If they request additional data or documentation, you should quickly provide it because it impacts how long they have to decide your appeal. If you don’t produce this requested documentation, your appeal could be denied.
The insurance company is supposed to provide an objective review of your claim when you file an appeal. In practice, that does not always happen. Regardless of what they say about the process or the rules that they need to follow, disability insurance companies may be predisposed to confirm their own initial decision when you appeal a denial. The good news is that the law gives you further rights. The insurance company is not the judge and jury when it comes to your disability benefits claim. That role belongs to the federal court.
You can file an additional appeal of your ERISA long term disability denial in federal district court. This is a valuable and important way to get a neutral review from someone unaffiliated with the insurance company. However, the scope of this process is limited, and the procedure is complicated.
As we described above, you will not be able to testify in this hearing. The judge will decide the case on the record, and their review is limited to deciding whether the insurance company made a mistake in denying your claim based on what they had to review. The judge will conduct a de novo review, which means they take a fresh look at the record and they do not give any deference to the insurance company’s decision. However, judges do have leeway to augment the administrative record in some circumstances.
If you are unsuccessful at the district court level, you still have another option left. You can go to the federal appeals court and ask for a review of the district court’s decision. When the appeals court reviews the case, they only look at the district court’s decision to see if the judge made an error when denying your appeal. There will be no testimony, and you cannot introduce any additional evidence. An argument may take place in front of the judges, but the appeals court will not take a fresh look at your case.
There are three possible outcomes when you file an appeal in federal court:
- The judge could agree with the insurance company and uphold the denial of your benefits.
- The judge could side with you and decide that the insurance company was wrong. The court decision could order that you receive benefits.
- The court could decide that the insurance company was wrong about a particular issue. Instead of ordering benefits, they could remand (return) the case back to the insurance company to reconsider that particular issue. This happens very rarely, but it is possible. In most cases, the court will decide whether you deserve benefits.
Simply stated, you should not attempt to file a long term disability claim denial appeal on your own, no matter how easy the insurance company makes the process seem. The disability insurer may mislead you into unknowingly committing a fatal error that seals the fate of your disability claim.
When you deserve the long-term disability benefits you paid for, don’t risk losing them for the rest of your life. Instead, work with a long term disability lawyer to protect your rights. J. Price McNamara is a dedicated and compassionate long term disability lawyer with more than 30 years of legal experience. He focuses his practice on ERISA claims and helping disability clients recover the benefits they need and deserve. Contact us today for a free case consultation.
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