Any number of medical problems could keep you from being able to continue with full-time employment. You may have a major physical impairment like a chronic back pain disorder, a major mental impairment like depression, or a combination of both physical and mental conditions. Dealing with debilitating and disabling medical conditions can be exhausting and may consume all of your energy. That is why it can be so disheartening when a long term disability (LTD) insurance company denies your claim disability benefits.
If your claim for benefits has been wrongfully denied, improperly delayed, or unfairly terminated it is important for you to be familiar with the appeal process. The more you know about LTD appeals, the better equipped you will be to submit an appeal quickly and efficiently to avoid further delays. We know your efforts are better spent on healing and getting better- not battling with your insurance company.
Read and Understand The Denial Letter
Your denial letter should specify why your claim was denied and how to file an appeal. Pay close attention to the reasons given for the denial so you can determine how you proceed with your appeal. For example, if you were denied because the insurance company stated your claim file lacks “objective documentation”, you would want to submit additional CT-Scans, x-rays or MRIs.
The denial letter should identify the deadline to file an appeal and explain where to file your administrative appeal. If you miss the deadline or filed the appeal in the wrong place, then the insurer may deny your claim. In short, make sure that all your paperwork is submitted on time. Your insurer must give you at least 60 days to file an appeal under federal law, but many LTD policies allow 180 days to file an appeal.
Steps to Starting An Administrative LTD Appeal
Let’s assume that you are required to file an administrative appeal. A lot of work goes into filing an appeal and your time to file the appeal an LTD denial is limited. Thus, whether or not you hire an attorney to represent you, you should take immediate action and take the following steps in appealing a long term disability denial.
Step 1: Request the Long Term Disability Claim File, Policy and Plan From The Insurance Company
If your LTD policy was provided as a benefit of employment by your employer, then a federal law known as ERISA applies to your claim. ERISA is a federal act that is widely recognized as an extremely pro-insurance company law. The ERISA regulations are pro-claimant with respect to at least one of its provisions. ERISA regulations require long term disability insurers to provide you, on request and free of charge, with a complete copy of your entire claim file, which should include copies of all documents, records, and other information relevant to your claim for benefits.
Thus, before you file your formal appeal (and assuming you have enough time remaining in your appeal period), request a complete copy of your long term disability claim file in writing from your insurer (i.e., via fax, mail or email). A claim file consists of all medical records, internal notes and memos, internal correspondence, outside doctor reviews, surveillance video and any other information the insurance company used to make a decision on your claim. You need to know what is in your claim file before you file your appeal in order to know what additional information you can submit in order to have your claim approved. For example, you may discover that the insurance company was missing medical records from a doctor that you thought the insurance company had already considered. If you discover records are missing, you can provide them with your appeal to make sure all positive medical evidence is in the claim file when the insurance company renders its decision.
A request for your long term disability claim file might read:
“I have received your denial letter dated [date of denial/termination letter]. In accordance with the U.S. Code and ERISA regulations, please provide me with the following documents within the next 30 days: the full Long Term Disability (LTD) Claim File including all computer records, internal and external correspondence, investigative reports, and attorney or legal department review documents relating to this LTD claim and appeal. As you are aware, ERISA provides a daily monetary penalty for the failure to provide the materials requested within a reasonable time. I reserve all rights under any potentially applicable coverage under my long term disability policy. I will later notify when I intend to file my formal appeal.”
The denial letter will usually indicate where to send your letter. You should submit your request in writing to this address with your claim number. You should also send it by certified mail in case you need to later show proof of your request.
Step 2: Request Your Entire Personnel File
If your disability claim was denied or terminated during the “own occupation” period of the claim you will need to prove that you cannot perform the material duties of your own occupation. Your personnel file with your employer should contain a job description of your position with the employer, or otherwise provide detailed information concerning the duties and responsibilities your job required. Some employers prefer that such requests be reviewed by their legal department, so it sometimes takes employers awhile to comply with your request. Thus, you should not delay this request and make sure the request is in writing.
Step 3: The Initial Appeal
Your appeal should be in writing and clear as to its intent. For example, you may start your letter with a sentence that says something like, “Please accept this letter as my formal appeal of your adverse decision dated [date of denial/termination letter].” You should make your appeal letter more of a cover letter, telling the insurance company why you disagree with its decision, and what information the claims handler will find in your appeal packet (the documentation mentioned below) that will change the denial into an approval.
Remember: any information you fail to submit with your appeal may never be heard or considered by a court of law in litigation. You should carefully consider all of the information you would like to include with your appeal before sending it via certified mail, fax or e-mail.
If your disability policy is part of a group plan subject to ERISA, you will have 180 days send your written appeal and supporting medical evidence. These time limits are very important! That is why you must read the denial letter and your disability policy carefully to determine everything you must do to make sure your appeal is timely and properly filed. Remember – if you have a claim governed by ERISA you will not have the opportunity to testify or submit any new evidence during the federal court lawsuit. That is why you should make sure to “pack the record” with all the evidence to support the claim that you can possibly muster.
Why Are You Given 180 Days To File A Long Term Disability Appeal?
Legal Representation in Long Term Disability Insurance Claims
Although based in Florida, the Ortiz Law Firm represents claimants across the United States. If your LTD claim has been wrongfully denied, delayed or terminated and you’d like to speak to an experienced Long Term Disability Insurance Attorney contact us at (866) 853-4512 to schedule a consultation. We can help you evaluate your claim to determine if you will be able to access Long Term Disability Benefits and how to move forward with the process.