When you cannot work for the long term because of an injury or health condition, your job may provide you with certain benefits. One valuable employee benefit is a long-term disability policy that pays you when you cannot work for an extended period. However, long-term disability insurance benefits are not always easy to get, even when you hold the policy. Insurance companies know that J. Price McNamara ERISA Insurance Claim Attorney means business when handling long-term disability claims. We have stood up to major disability insurance providers for over 25 years, and we regularly obtain settlements and verdicts involving hundreds of thousands or millions of dollars for deserving clients. Reach out to Austin Long-Term Disability Lawyer to learn more about how we might assist with your claim.
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Insurance Companies Make Long-Term Disability Claims HardLike many other benefits that provide protection, you must go through an insurance company to qualify. The same company that decides whether you are eligible for benefits is the one that writes the check. You can imagine exactly what that means for your claim. They are a referee who gets to call their own game in many respects. Every "i" must be dotted and "t" crossed for your long-term disability insurance to approve your claim. If not, you may find your claim denied and need to fight for the benefits that you believe you deserve.
Call Us to File Your ClaimYou must pay a lot of attention to your ERISA claim when you file it. If you make a small mistake, you can lay the grounds for the insurance company to reject the claim, forcing you to appeal. You need a lawyer who will know how to follow every timeline in the policy and every paperwork requirement. They are traditionally very strict about everything because an insurance company is looking for a reason to deny your claim. Your policy dictates much of your entitlement to long-term disability benefits by the exact terms of that policy. For example, your policy will define disability in the company’s words to determine whether you have a qualifying condition. In addition, your policy will also describe deadlines and requirements that you must meet to receive benefits. Therefore, before you even file your claim, you should pay very close attention to the terms and conditions of your policy. The claim form can be very complex, and one mistake can have disastrous consequences. That's why you need our long-term disability lawyers to review your policy and file your initial claim for benefits.
Why the Insurance Company May Deny Your Claim?There are numerous reasons why an insurance provider may deny your claim. Reasons for denial include:
- The condition does not meet the plan’s definition of disability - this is a common issue. There is no one definition of "disability" in the ERISA law. The policy is left to define disability. What is worse is that many insurance companies depart from the plan's language to deny as many claims as possible. They may even change the definition of disability even after you received benefits for some time.
- Your claim does not include sufficient medical evidence of a disability - the most crucial part of your initial claim is the medical evidence that backs it. You need evidence of regular medical treatment and a diagnosis of the disability that is the basis for your claim. In addition, you must include a doctor's statement that gives their opinion of your disability and inability to work. You can expect the insurance company to go over your medical records with a fine-tooth comb.
- The insurance company has found evidence that undercuts your claim - insurance companies often have someone following you. At the same time, they evaluate your claim to ensure that your condition is consistent with what you have represented on paper. They can look at your social media or even observe you when you are not looking. If they uncover inconsistent evidence, they may deny your claim.
- The insurance company claims that you suffer from a pre-existing condition - long-term disability insurance policies do not cover pre-existing conditions. However, there is room for difference of opinion in whether a condition is pre-existing. These types of denials are often the reason for heated litigation between claimants and the insurance company.
Get an Attorney When They Deny Your ClaimIf you did not have an attorney when the insurance company rejected your initial claim, you should hire one immediately upon learning about the denial of your claim. The appeals process happens quickly, and you need to take it seriously from the very beginning. You face an uphill battle during the appeal, but you can win if the law and facts support your case. Your attorney will review the denial letter to understand the basis of the decision. They will then work to strengthen your claim for the appeals process. If your claim was missing critical medical information, your lawyer will ensure that your physician adds it to your file. If a dispute arises over the terms of the long-term disability policy, your attorney will argue your position on appeal, attempting to persuade the insurance company or judge why you deserve benefits.
ERISA Is Not a Claimant-Friendly LawWhile there is a specific law that governs long-term disability insurance, it is not exactly one that is friendly to the injured employee. Long-term disability claims are governed by the Employee Retirement Investment Security Act (ERISA) because they are employee benefits. You would expect that Congress would have passed a law heavy on employee protections. Instead, the law has created a system skewed towards insurance companies. The law creates a system in which insurance companies get a great deal of power over you and your family’s future. The insurance company gets to make the initial decision about whether you can qualify for long-term disability benefits. Since they are writing the check, you can expect that they will be very stringent about approving your initial claim for benefits. You must be very precise with your paperwork because the insurance company can deny your claim for minor errors or gaps. Unlike other insurance claims, they may not even be subject to bad faith claims for denying your claim. While the rules have recently changed to make it easier to take action against an insurance company, they still have room to operate.
You Can Appeal the Denial of Your ClaimERISA allows you to appeal your claim denial. The law benefits the insurance company because the first level of appeal is placed squarely in their hands. Of course, the insurance company assigns the appeal review to someone different from the person who denied it in the first place. Nonetheless, you may be questioning how the same insurance company that denied your claim in the first place will objectively give you a fair hearing when you appeal the denial. Some people question why they should even bother with this appeals process. This question is a valid concern, but you cannot let it get in your way.
You Must Participate at All Stages of the AppealThere is a compelling reason why you need to participate fully in the appeal at the insurance company level. ERISA requires you to fully build your record at the insurance company appeals stage of the process. Even if you doubt that the insurance company itself can be a fair decision-maker, you must still participate and put all possible evidence in front of them for their decision. You need to expend all possible effort in building the record because you cannot add any information to it at the next stage of the process. Judges are very limited in what they allow you to add if they get the case. If you count on supplementing the record at the next level of appeal, you will likely be disappointed. If you do not put in all your effort at the insurance company appeal phase, there may not be enough in the record for the judge to overturn their denial.
You Can Appeal to a Federal CourtA federal judge will review the same record you provided the insurance company at the administrative appeal. While you cannot add to the record, the one thing working in your favor is that the judge will not give any deference to the insurance company's decision. The judge will review the record from scratch, deciding based on their own opinion of whether you deserve benefits. If you do not win your case on appeal to the federal district court, you have the right to appeal further to the Court of Appeals. This court will also review the same record used at the insurance company appeal stage. The federal appeals court reviews the case to see if the district court made an error.
Austin Long-Term Disability FAQsHere are some often asked questions about ERISA long-term disability claims.
How long do I have to file an appeal of my denial with the insurance company?There are tight timelines to file an appeal of your long-term disability claim denial. You have 180 days from the date of denial to file an appeal. However, you do not want to wait until close to the deadline to begin work on your case. If the insurance company denied your initial claim, you might need to supplement your claim with more information to persuade the insurance company during the appeal, and that takes time.
How much does it cost to hire an ERISA attorney?You are probably worried about having enough money to hire an ERISA long-term disability attorney. After all, you cannot work, and money may not be coming in as you need it. ERISA attorneys work for you on a contingency basis. You do not need to write a check to them upfront to get them working on your case. Instead, they receive a percentage of the money that you recover. Some people are hesitant to pay a percentage of their recovery to an attorney. However, given the complexity of ERISA appeals, you may not even receive benefits at all if you are trying to appeal on your own.
Do I need an attorney to handle my case?As you can see, the insurance company gets to be the judge and the jury throughout much of your case. Without an experienced attorney who knows the system, you can get the short end of the stick from an insurance company with a track record of aggressively denying claims. You may end up in a protracted legal fight where you need a lawyer. Always consult with an experienced attorney from the start of the claim process.
Call Our Austin Long-Term Disability AttorneysLong-term disability insurance claims and appeals can involve complex law and medical issues. An ERISA attorney must understand both the medical challenges in your case and how to persuade an insurance company or judge of your disability. Simply stated, you need a determined and experienced ERISA attorney for your claim to have a better chance of getting benefits. The insurance company has an entire apparatus that they throw at your claim, and you must have an equalizer. J. Price McNamara ERISA Insurance Claim Attorney has helped countless people in your shoes, filing their initial claim and when the insurance company throws up roadblocks. We know how to get results for our clients. Call us today at (713) 300-0462 or contact us online to discuss your case.
This has been a very difficult time for myself and my family. Mr. Mcnamara did his best to be as empathetic and compassionate as possible. He is very knowledgeable and a man of great integrity. Nicole