Aflac bills itself as America’s most recognizable supplemental insurance company. If recognizable comes from the barrage of television commercials the company pays for, then Aflac is undoubtedly recognizable. However, recognizable does not necessarily mean trustworthy.
When you need Aflac to be there, you may find that the company hides behind legalese or an interpretation of your policy that does not exist in reality to escape their obligations to you. In other words, their television commercials portray a different reality than the one that you may face when you need Aflac to pay for a claim when you expect it.
The company may unfairly deny your claim when you rely on Aflac to pay for your ERISA long-term disability insurance benefits. You had filed your claim, likely grateful that your job provided you with this crucial benefit. However, the reality often sets in when you receive a denial from companies like Aflac.
When this happens – or you need to begin the claim process – you need help from a long-term disability attorney from J. Price McNamara ERISA Insurance Claim Attorney. We obtain six and seven-figure settlements for our clients, and we’re ready to take on Aflac for you.
Table of Contents
- Unfairly Denial of Long-Term Disability Claims
- How Aflac Handles Your Initial Long-Term Disability Claim
- Why Aflac Denies Your Long-Term Disability Claim
- You Can Appeal a Wrongful Claim Denial
- Appealing to the Insurance
- Reasons Why Appellants Win Their Cases
- Contact a ERISA Long-Term Disability Insurance Attorney
Aflac Often Unfairly and Wrongfully Denies Long-Term Disability Claims
A lawsuit that former employees filed sheds light on the corporate culture at Aflac. These employees alleged fraud and abuse in every aspect of the company, including its dealings with customers. The insurance companies pressure employees to sell policies, so the company can book revenue. The problem is when policyholders file claims for the benefits they believe they deserve based on the policy’s language.
What should be a process where a disabled worker gets financial relief can become a nightmare that lasts for years.
How Aflac Handles Your Initial Long-Term Disability Claim
When you file an initial claim for disability benefits, you will include the documentation that will show that you are disabled within the meaning of the policy. Your eligibility for benefits hinges on the plan’s definition of disability and the quality of the documentation you provide. Your initial application will need to show that you cannot perform the duties of your job (assuming that your plan gives benefits when you cannot do your job, as opposed to any job).
The insurance company will review your initial claim and decide whether to grant your benefits. There are some cases where the claimant is very obviously disabled under any definition, and even the insurance company realizes that they will not have a leg to stand on in denying benefits.
However, if your case is even a close call, you will not get the benefit of the doubt from the insurance company. Their profitability depends on denying a certain number of claims, and they will not hesitate to deny yours.
Why Aflac Denies Your Long-Term Disability Claim
When Aflac denies your claim, they must provide you with the reason. The main reason why they will deny your claim is they do not think you meet the plan’s definition of disabled.
They may reach this conclusion for many reasons (besides their self-interest in denying your claim), including:
- Their so-called independent doctors have reached a different conclusion than the treating physician who has repeatedly examined you in person.
- They have hired surveillance people who may have followed you or checked your social media and learned some facts that lead them to challenge whether you are disabled.
- Your claim may have missed some key documents.
- They think that, notwithstanding your disability, you can still perform your job duties.
If there is ever a close call, you can expect Aflac to deny your claim and force you to fight. They may deny claims to force you to settle for less than you deserve under the terms of your policy.
You Can Appeal a Wrongful Claim Denial
Many people feel taken aback and angry when they receive a claim denial. However, you do not have the time to let your anger get in the way. If you think the insurance company wrongfully denied your claim, you have limited time to do something about it.
At this point, a dense and complex law called ERISA takes over. The law gives procedures and rules that you must follow for you to have your voice heard. You must follow a strict process to get a review of the denial. The first thing is that you must act quickly.
ERISA gives you 180 days to appeal the denial. Your appeal requires far more work than just explaining why you think the insurance company was wrong, so you must begin to act quickly. Besides, the sooner you file your appeal, the quicker you can get to court if necessary.
When you appeal an ERISA denial, you have the burden of proof to show that you meet the plan definition of disabled because this is what the benefit decision is about. If your case goes to court, you must show that the insurance company made an error and unreasonably denied you benefits.
Building the Appeal Record in Your ERISA Case
The way that you will win an ERISA appeal is by building the most robust appeal record possible. The insurance company has provided you with the reason for the denial and the information they relied on to reach that decision.
Working with an experienced ERISA long-term disability lawyer, you will include the following in the record:
- Statements from your treating physician that details your disability and show how you meet the plan’s definition of disability
- Objective evidence such as MRIs and test results that evidence your disability (the insurance company wrongfully takes the statements of your own treating doctor with a grain of salt and insists on objective evidence, even if the policy does not require it)
- Statements from people who see you every day and know you that describe their observations of you
- Supplementing your medical records with documentation that the insurance company may have missed
You Must Always Appeal to the Insurance Company and Take it Seriously
You have a limited time to build the record for the insurance company appeal, but there is quite a bit riding on the strength of your record. It is a fair assumption to make that you will lose the insurance company appeal because this is what happens most of the time.
The insurance company is simply too conflicted and has too much self-interest in denying your claim to objectively decide it. You are really gearing the appeal record to the federal court, where you will go after the insurance company likely denies your appeal.
The insurance company has a limited amount of time to review your appeal. They must issue a decision within 45 days of receiving your appeal. The law says that Aflac can request one 45-day extension for a decision, provided they explained why they needed more time.
You Can Only Build the Appeal Record Once
ERISA has a strict rule that only allows you one opportunity to build an appeal record, and that is before the insurance company. The procedure is that the federal judge will review the record and the insurance company’s reason for the denial to decide whether they made a mistake.
You do not get to build your record or add anything more to the appeal file at this stage. If you forgot to include something earlier or did not think of it, you will be out of luck in federal court. Therefore, you will need to hire an ERISA long-term disability lawyer early in the process because there is a time when it may be too late.
Appealing Your Claim Denial to Federal Court
Assuming that you do not win the appeal at the insurance company phase (although some claimants sometimes win if they can supplement the initial claim with solid evidence in the appeal record), your next step is the federal district court. You cannot go to federal court until you have been through the insurance company. The federal judge is the one who will review the record and make an objective decision.
Depending on the language of your policy, the federal judge may:
- Decide on your claim, reviewing the entire record de novo (which is a legal term for “from scratch” and not considering the insurance company’s decision)
- Review the insurance company’s decision to see if it was unreasonable (this standard of review is more generous to the insurance company)
Reasons Why Appellants Win Their Cases
Either way, you will get an unbiased review of your case from someone who does not have a financial interest in the outcome. Judges have overturned insurance company denials.
Some of the reasons that claimants win appeals include:
- You have provided enough medical evidence to prove that you have met the policy’s definition of disability.
- The insurance company tried to cherry-pick one or two helpful facts that flew in the face of a compelling body of evidence.
- The insurance company has misread or changed the definition of disabled in the policy.
- The insurance company relied on its own doctor’s opinion when they never treated or saw you, to the exclusion of your treating physician’s opinion.
If you do not win your case in federal district court, you can file your appeal in the federal appeals court. The judges will review the district court judge’s decision to ensure that it was correct, and they will reverse it if the judge made a mistake.
Why You Need to Work with an Experienced ERISA Attorney
The ERISA long-term disability benefits process will give the insurance company a home-court advantage because of the procedures that the law mandates. However, you can begin to neutralize that advantage when you hire an experienced ERISA attorney who knows the system and how to fight insurance companies when they unreasonably deny you benefits.
Here is how an experienced ERISA lawyer can help you:
- We can help you with the initial application, reviewing both your plan and the documentation requirements to help you compile the strongest possible initial application.
- If you have been denied benefits, we will review the insurance company’s reasons for the denial and help you build a strong appeal record that can address the insurance company’s concerns and put you in a better position to win your case.
- We will present your case that argues why the insurance company made a mistake by not initially granting your benefits claim.
- If the insurance company tries to settle your case, we can assess your chances of winning the appeal and the offer’s value to advise you whether to settle. We can then negotiate with the insurance company.
- We will take your case through the federal court system if you lose the appeal, making the strongest arguments to show why the insurance company was wrong.
- We will appeal your case if the insurance company tried to cut off your benefits once it granted them.
Long-term disability benefits are crucial in your and your family’s financial life. The insurance company plays for keeps because they know that the total value of your claim can exceed $1 million over its life. You cannot afford to be without your own experienced lawyer who will strongly advocate for you throughout the process.
Call an Aflac ERISA Long-Term Disability Insurance Attorney
It does not matter who the insurance company is or how big they are. They are for-profit companies that try to maximize their profits by paying out as little as they can on as few claims as possible. Your best chance is with a lawyer at your side.
At J. Price McNamara ERISA Insurance Claim Attorney, we treat all insurance companies the same way when they are unreasonably trying to avoid paying our clients what they legally deserve. The ERISA long-term disability insurance appeals process requires an attorney who knows how to fight because these insurance companies will pull out every stop of their own to not pay you. To discuss your case, you can contact us online or call us today at (504) 420-6962.