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If your insurance company denied your disability claim, you shouldn’t shift into panic mode. Insurance company denials often follow a distinct pattern. You submit a claim. You follow their instructions. You anticipate a payment, then a rejection letter arrives. Of course, it’s frustrating. It’s not what you expect, but a disability denial letter doesn’t mean that it’s over.
If you believe your insurance company should cover your disability claim, you have a right to demand reconsideration. If your insurance company doesn’t properly address your inquiries, you have access to a progression of resources to hold them accountable. Disability attorneys understand the complex issues involved. They are your first-line resource for resolving claim denial issues. Here are three additional reasons why you shouldn’t panic.
When an insurance company rejects a claim, they realize that some people simply go away but others won’t. That’s why insurers maintain your claim documentation until you no longer have a legal right to make a claim. Your claim file should include your documentation, medical records, and the insurance company’s rationale for denying your claim. If you want to know why they didn’t pay, you have a legal right to demand access to the answers in your file.
The insurance policy that provides your disability coverage is a contract. It grants you certain rights and benefits in exchange for a premium. If your coverage is part of a group plan and your employer pays the premiums, your role as a beneficiary entitles you to an explanation of your disability denial. An insurer must explain how and why your claim isn’t covered under the policy terms. Even if your disability denial letter didn’t thoroughly explain their reasons, your claim file should document relevant claim issues such as these:
You can compel your insurance company to provide reconsider their decisions. You can ask for a better explanation than the one in their formal disability denial letter. You may also request documentation from your claim file and a complete copy of the applicable insurance policy. The additional information you obtain should help you understand whether their position is valid.
If you’re still not satisfied and the insurer won’t reconsider their disability denial, you have alternatives. This is important because some insurance contracts contain clauses that require dispute resolution via binding arbitration. Others must grant you permission to file suit, but they do so only after you comply with all policy conditions.
If your disability insurer doesn’t respond to your inquiries, you can assert your rights under Louisiana Revised Statutes. Under LRS 22, §1964 “Methods, acts, and practices which are defined as unfair or deceptive,” insurers have a legal duty to supply the answers to your questions. Provision (14) prohibits insurers from “Failing to acknowledge and act reasonably promptly upon communications with respect to claims arising under insurance policies.”
The Louisiana Department of Insurance allows you to make a complaint without filing a formal lawsuit. You may complete an online complaint form to initiate the process. Before they take action, they may ask you to attempt to resolve your differences with your insurer.
ERISA Section 503 regulations implement standards that employers must follow when administering certain employer-sponsored disability plans. The agency revised its claim guidelines after research supported the theory that insurers disputed long-term disability claims as a cost-containment measure. The agency determined that 64.5% of ERISA-related coverage litigation involved long-term disability denials. Health care disputes made up 14.4% of ERISA-litigated cases. Pensions made up only 9.3%.
ERISA requires employers to inform employees of their available benefits. They must also handle certain claims based on ERISA regulations. Employers must provide each employee with a Summary Plan Description. The document must explain the plan type, benefits, availability, employee contributions, termination information, claim handling procedures, and other details. An SPD must also explain any coverage dispute processes and any rights available under ERISA.
Disability claims present complex submission and compliance requirements. They’re subject to coverage denials even when you fully comply. Before you decide to shoulder the responsibility or you shift into panic mode, consult with a disability attorney. Attorneys understand state and federal regulations and statutes and claim submission complications. They interact with insurance companies, employers, and government agencies. It’s an overwhelming process for a person who’s recovering from disabling injuries.
Your initial disability consultation is usually complimentary. You discuss your claim circumstances with a legal representative and receive feedback about your legal options. If your insurer has already rejected your claim, an attorney explains your alternatives and informs you of any important deadlines. If you want to move forward and fight your disability denial, the decision is up to you.
Disability denials can seem devastating, but it is not the end of the road. In most cases, there are multiple steps you can take in order to ensure you get the benefits you deserve. Disputing the denial alongside an experienced attorney will give you your best chance at a favorable outcome.
Oftentimes, fighting a disability denial means providing more documentation to prove your disability. You have rights under the law that allow you to dispute a disability denial. An ERISA lawyer will be able to review your case and help you determine the best way to proceed after a disability denial.
The best way to increase your chances of getting disability is to make sure your documentation is thorough and detailed. It is also best practice to speak with an ERISA Disability Attorney in order to help create an airtight case for disputing a disability denial.
Receiving a denial from an insurance company can be devastating, and many policyholders and beneficiaries feel helpless and confused. Such feelings are normal after a denial, but it is important to remember you may be able to take legal action against an insurer and obtain the benefits you need to survive. Call an ERISA Long-Term Disability Denial Lawyer today to learn more.
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