Disability and Injury FAQs
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When should I hire a lawyer?
The most critical stage in an LTD claim for disability insurance benefits is the appeal stage. Once the internal “administrative” appeals directly with the insurance company have been exhausted and a lawsuit has been filed, no new evidence can be introduced to the court. You do not testify. Your doctors do not testify. You cannot introduce any new written statements to the court after your appeals are completed. There are no trials, hearing, or depositions. The court simply reviews the administrative claim file and does so with legal obligation to defer to the insurance company’s decision. It is essential that an experienced LTD attorney review the claim file at the appeal stage in order to determine what additional medical and/or vocational proof needs to be added to the administrative file and to determine what adverse information needs to be rebutted.
Should I file a complaint with my state’s Department of Insurance?
If your claim is governed by federal ERISA regulations, then your state’s insurance laws are “pre-empted,” which means your state’s Department of Insurance has no jurisdiction. Many insurance companies do include stock language in their denial letters advising the denied claimant that he or she can file a complaint with his or her state’s Department of Insurance. This is in fact true. However, doing so is generally a waste of time. You will simply receive a response a few months later from the Department of Insurance saying that they lack jurisdiction in the matter. You will be no better off and your appeal deadline will be that much closer, if not already expired.
How long does the insurance company have to make a decision on my appeal?
The insurance company has 45 days from the date of your appeal to make its decision. This can be extended by an additional 45 days if the insurance company requests an extension in writing within the first 45 days.
Why should I bother appealing with the same insurance company that has already denied my claim?
You must file an appeal with your insurance company because you are required to exhaust all mandatory internal appeals before filing a lawsuit against the insurance company. If you file a lawsuit without “exhausting” the internal appeals process, your claim will be dismissed. By the time your claim is dismissed in court, your internal appeal deadline with the insurance company might have already expired.
Why is it so important that I appeal?
The Employee Retirement Income Security Act of 1974 (“ERISA”) requires you to exhaust your administrative remedies before you can file a lawsuit. The internal appeal process allows the insurance company an opportunity to correct its mistakes and avoid a lawsuit. If you do not give the insurance company the chance to right its own wrongs first, most courts will not allow your lawsuit to proceed.
The internal appeals process is also a very important opportunity for you, the disabled claimant. It gives you a chance to load your claim file with information supporting your disability claim and to correct any misconceptions. It is imperative that you submit everything that may possibly help prove your disability and your credibility. (See “How do I appeal my own denial of disability benefits?”)
Do I have to file an appeal in every case?
As stated in response to the previous question, it all depends on how you obtained the policy. If the policy is through a private employer, employee organization or union, then you may be required to go through the appeal process before going to court. If you have an individual policy, or a policy provided by a government employer or church employer, then you may not be required to file any appeals before resorting to litigation. Because these rules can be very complicated, you should obtain a free consultation from an experienced disability attorney to explain to you your rights. Feel free to call us at (850) 308-7833.
Can I file a lawsuit against the insurance company without first filing an appeal?
The answer to this question depends on the type of disability insurance contract you have.
Most employees have disability insurance coverage through a group plan with a private sector employer. If your employer is large enough, or if you obtained your policy through an employee organization or union, then ERISA rules and regulations come into play. According to ERISA, you must “exhaust” your administrative remedies before you can file a lawsuit. This means you must follow the terms of the insurance policy and go through each step of the appeals process directly with the insurance company. If the insurance policy states that you must file one appeal, then you may only need to file one mandatory appeal. If the insurance policy requires you to file two appeals, then you must go through two appeals before filing a lawsuit. Other insurance policies have one mandatory appeal and one “optional” appeal.
When You May Not Have to File an Appeal
There may be other situations where you do not have to file an appeal at all before filing a lawsuit. Generally, you do not need to appeal if you have an individual policy purchased directly from an insurance agent or broker, or if your policy is sponsored by a government or church employer directly (in other words, if the policy is not through a union or employee organization). In such situations, you may be entitled to file a lawsuit after your first denial.
You may have questions as to whether you are required to file an appeal, or whether you should participate in the “optional” appeal process. If you have such questions, you should immediately seek legal advice from an attorney familiar with ERISA disability cases. Please call at (850) 308-7833.
How long do I have to file a lawsuit after the insurance company has advised me that I have “exhausted” my administrative appeals?
If there is no mention of a specific time limit to file a legal action (lawsuit) in your LTD policy, then the time limit is the same a breach of contract claim in your state. However, most LTD policies have a specific deadline to file a legal action. This specific language is usually towards the back of an LTD policy. Typical policy deadlines range from 1 to 3 years, but United Parcel Service’s LTD policy deadline is 6 months.
Oops. I missed the 180-day appeal deadline. What do I do now?
You should not assume all is lost. You should immediately seek legal advice from an attorney like Mr. Ortiz who is experienced in handling ERISA disability cases to determine whether the typical 180-day deadlines apply to your claim. We can be reached at 850-308-7833.
Do I have a limited amount of time to appeal the denial of my disability benefits?
Yes. A disability insurance claim is not like an automobile accident claim, where you may have years after the incident to file a lawsuit. Under ERISA rules and regulations, you only have 180 days from the date on the insurance company’s denial letter to file your appeal. It is critical that you give notice of your appeal before this deadline.
Note: Some long-term disability policies provide for a second level appeal, and the deadline is often shorter than 180 days.