In this step-by-step guide you will learn about the long term disability appeal process and how you can be one-step ahead for filing your appeal.
If you received a denial of your ERISA long-term disability claim 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 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 in error and the insurer should overturn it.
You may win an ERISA appeal if you have the right legal help such as an experienced long term disability lawyer. Here are the steps in the process that you need to follow to have a 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 do not already have a lawyer, the denial of your claim is a surefire indicator that you now need one. The ERISA appeals process is one that you must take seriously from the first minute. The insurance company closely reviews claims, and they must follow federal ERISA rules (or risk facing a lawsuit). While you work with the insurance company during the appeal, they are also your potential opponent in future litigation. You cannot face them alone.
The ERISA long-term disability appeals process is very technical. It can require detailed medical evidence, testimony, and extensive documentation. This is not something that anyone should try to do on their own.
An experienced ERISA attorney knows how to deal with disability insurance companies. They 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 the insurance company and winning.
If you are worrying about whether you can afford an attorney, you should not. There are contingency agreements available that do not cost you any money out of your pocket for an attorney. The lawyer only receives payment if you win your case.
The insurance company is legally obligated to explain the grounds of its decision to you.
They may deny your claim because:
- They did not believe that your condition fit the definition of “disability” contained in the policy.
- They did not think that the medical evidence provided with your claim supported your contention that you had a long-term disability.
- The insurance company believed that your application did not contain the required documentation.
- Your application may not have followed the timeliness requirements.
- The insurance company thinks that they observed conduct or behavior that was inconsistent with your application (Yes, the insurance company may employ investigators to observe you or look at your social media)
After you have received the decision, you should review your claim application to see if the insurance company’s reason makes sense or if they made a mistake. Either way, you can correct the mistake or provide additional evidence during the appeals process. Do not try to do this alone, no matter how easy the insurance company tries to make you think it is. Discuss your administrative appeal with your attorney to see how you can counteract their arguments.
There are several key documents that you should review as part of your 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 can always request this from the insurance company. They must provide it to you upon request.
Then, the insurance company must also provide the documents that it reviewed in reaching its decision to deny your claim. Recent changes to the federal rules governing ERISA long-term disability have made the process far more transparent. The insurance company must now give you the documents upon request. This is an opportunity on which you should not pass. Your lawyer will ask for these documents and will review them closely.
There must be a reason for an appeal. In other words, you have to show that the insurance company was wrong. Either they were missing a key part of your case, or they 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. Usually, claimants will point out multiple reasons why the insurance company was wrong.
ERISA appeals require planning and forethought, even when there are tight deadlines. Insurance companies will need a detailed and compelling description of why they initially erred for you to have a chance to win at the initial stage of appeal.
You have to formally request an appeal when you receive a claim denial. It does not happen automatically. You ask for the appeal by sending a letter. When you ask for the appeal, you should state the reason and basis why you want the insurance company to reconsider its denial. This means that you have already reviewed the reasons that they provided for the denial and your claim to establish your arguments. Your lawyer can send this on your behalf as your authorized representative. You have strict deadlines for requesting the appeal. This is 180 days after you receive notice of the denial.
The insurance company will appoint someone to review your 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 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 be taking what your doctor says with a grain of salt. One of their favorite tactics is to send you to another doctor.
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 a ground for denial of benefits. Insurance companies could send you to this doctor at any part of the process. If you are appealing a denial, you can expect this as part of the process.
Remember, the key is to show that you cannot do your job, as opposed to just any job. Whether you receive benefits is a person-specific decision. You could have a physical job, and your injuries would 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 this and do not provide enough detail, you cannot trust the insurance company to fill this in to help you.
There are reasons why you need to invest all of the efforts that you can into developing your factual record at the insurance company appeal stage. While ERISA gives you multiple levels of appeal, it also limits what you can do at later stages. You have one chance to build a factual record, and that is at the insurance company 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 any evidence at that point.
As part of the appeals process, you have the right to conduct discovery. This means that you can obtain information from the insurance company that the insurer considered to make its decision about the benefits. In fact, you can obtain all of this documentation that is relevant to your claim. Federal regulations require the insurance company to make certain documentation available. If they fail to file these rules, you can sue them.
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
- The initial 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. This might show that 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. It can take 45 additional days if they need it, so long as they 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 the timeline of when they decide your appeal. The failure to produce this documentation could lead to denial of your appeal.
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, it may predispose them to confirm their own initial decision in the appeal. 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 denial in district court. While this is a valuable and important way to get a neutral review by someone unaffiliated with the insurance company, the scope of this process is limited.
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 in front of them. They will conduct a de novo review, meaning that 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 certain circumstances.
If you are unsuccessful at the district court level, you still have an option left. You can go to the appeals court and ask for a review of the district court’s decision. When the appeals court reviews the case, they will just 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 to the federal courts:
- 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. Their 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 the case back to the insurance company to reconsider that particular issue. This happens very rarely in a case, but it is possible. In most cases, the court will decide whether you deserve benefits.
In no case should you attempt to file an appeal on your own, no matter how easy the insurance company makes the process seem. It may well mislead you into unknowingly committing a fatal error that dooms your claim.
If you need the long-term disability benefits you paid for, don’t risk losing them for the rest of your life. Instead, hire a long term disability lawyer to protect your rights.
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