How to Appeal a Long Term Disability Denial: Advice for Your Appeal

You should not give up if your claim for long term disability (LTD) benefits is denied.  It is not unusual for an insurance company to deny disability claims, and you have the right to appeal the decision. Sometimes, claimants are “put on claim” and receive benefits after the appeal process—but not often.

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 wrongs first, most courts will not allow your lawsuit to proceed. Filing an appeal also provides you with an opportunity to present new information and additional medical evidence. 

Do I Have to File an Appeal?

ERISA Claims

If your LTD policy is a group disability plan provided by your employer, you are required under federal law—specifically the Employee Retirement Income Security Act (ERISA)—to “exhaust” all of your appeals before filing a lawsuit against the insurance company in federal court. Most policies only require a claimant to file one appeal before filing a lawsuit, but some require two.

This process is also a very important opportunity for you, the claimant. It allows you to bolster your claim file with supporting information and to correct any misconceptions. It is imperative that you submit any evidence that could possibly help prove your disability and your credibility.

Non-ERISA Claims

If you purchased an individual disability insurance plan not governed by federal law and your disability claim is denied, you may not be required to file any appeals before filing a lawsuit.

Appealing a Long Term Disability Claim Denial

Determine the Deadline to File an Appeal

The denial letter should identify the deadline for your appeal and provide the contact information for submitting your appeal letter. Under ERISA rules and regulations, you have only 180 days from the date on the insurance company’s denial letter to file your appeal. It is critical to notify the insurance company of your appeal before this deadline expires.

If you miss the deadline or send the appeal letter to the wrong place, then the insurer may deny your claim. Long term disability deadlines are very strict. You must submit your appeal letter prior to the appeal deadline or the appeal will not be accepted. Long term disability companies are not as forgiving as the Social Security Administration, which may accept a late appeal with a statement of good cause.

In short, make sure that all your paperwork is submitted on time. 

Understand Why Your Claim Was Denied

It is important that you understand why your claim was denied. Your denial letter should specify why your claim was denied and how to file your appeal. Read the letter carefully and pay close attention to the reasons given for the denial so you can determine how to proceed with your appeal.

For example, if you were denied because the insurance company stated your claim file was missing “objective documentation”, you would want to provide additional medical evidence such as CT-Scans, x-rays, or MRIs. If you do not understand why your claim was denied you should contact a long term disability attorney.

Request the Claim File

One of the first things you should do after you receive a disability denial letter is to request a copy of your claim file in writing from your LTD insurance company. You can request a copy of certified mail or fax. You should aim to obtain a copy of the claim file as soon as possible. The insurance company is required to provide you with a free copy of your entire claim file and policy if your claim has been denied or terminated.

Stack the Administrative Record With Favorable Evidence While You Can

The vast majority of employer-provided LTD policies are subject to ERISA. Under ERISA, once you’ve exhausted all your administrative appeals, the administrative “record” in your case is closed. In other words, if you file a lawsuit in federal court, the judge will be limited to considering only the evidence that was in your claim file at the time the claims handler issued his or her decision. That means you should pack or stack the record with favorable evidence during the appeal process.

What Kind of Additional Evidence Should You Submit?

First, you should index the entire claim file to make sure that your file already contains all your relevant medical records. If there are important medical records that are not in your file then that could help you understand why your insurance claim was denied. Your medical evidence should include all physician treatment notes, radiology and surgical reports, and emergency room records. If any records are missing, you need to get the missing records and submit them to your insurer via certified mail for consideration.

You should also try to obtain an opinion from your doctor that identifies your residual functional capacity (RFC) with respect to your physical and/or mental limitations. The physician can set forth opinions in a “To Whom It May Concern” letter or in an Attending Physician Statement (also called a Medical Source Statement or RFC Form).

The doctor should specifically identify your diagnoses, your resulting impairments, and how the impairments affect your daily activities. An RFC from your physician will also help you dispute any claims by a vocational expert that you are able to work despite your condition. If you see multiple doctors, try to obtain an opinion from each one.

It is useless for your doctors to write a note that makes simple, conclusory statements like, “This patient is disabled. Please give him/her all appropriate accommodations”. It is not necessary for the doctor to state that he or she thinks you’re “disabled.” It is more important for the doctor to identify your level of impairment. If your doctor is not willing to help with your case, you should seriously consider finding a new one who is willing to help.

Third-party statements from friends and family members can also be beneficial in the long term disability appeal, so ask those closest to you to write a letter. These statements should not give their opinions as to your medical issues or conclude that you are disabled. Instead, third-party statements should focus on their first-hand observations.

For instance, if your spouse has to help you get dressed in the morning or assists you with showering because you have difficulty doing these things on your own, he or she should include such details in a letter to the insurance company. If there are activities which you no longer do or that you do less often, such as cooking or household chores, they should include that information as well. These third-party statements also support your claim that your condition prevents you from working.

What is the Definition of Disability in Your Policy

An insurance company’s definition of “disability” in your disability policy can make a big difference in your long term disability claim. Some disability policies define disability as the inability to perform any occupation, while others state you are disabled under the policy if you cannot perform the material duties of your own occupation. Under some policies, in order for an occupation to qualify under any occupation standard, you must be able to earn at least a certain percentage of your pre-disability earnings at your new occupation.

You can usually determine how the insurance policy defines disability in your policy’s summary plan description, the denial letter, or in the insurance policy itself. If the insurance company conducted a vocational review, make sure the vocational expert used the correct definition of disability and an appropriate occupation when evaluating your claim. Insurance companies have been known to provide incorrect or incomplete information to medical and vocational experts.

When to Hire an Attorney to File Your Appeal

Generally, it is best to hire a disability insurance attorney as early in the long term disability appeal process as possible. Insurance company adjusters are trained in how to deny claims. They are generally more familiar with the application and appeal processes. Insurance companies will not hesitate to use your unfamiliarity with the disability claims process against you. Missing just one deadline could prevent you from enforcing your rights and from obtaining any benefits. Having an experienced LTD ERISA attorney on your side vastly improves your chances of receiving some or all of your benefits.

Why Hire a Long Term Disability Attorney?

Mr. Ortiz and his staff offer support and advice to clients after a claim is denied and throughout the appeal process. Here are the most important things he will do to help with appealing disability claims:

• Review and understand the reasoning behind your long term disability claim denial.
• Acquire missing medical records and evidence that supports your claim to include with your appeal letter.
• Obtain opinions written by your treating doctors concerning your specific impairments resulting from your injury or illness.
• Complete the appeals paperwork.
• File your LTD claim appeal within the required time limits.

As you can see from the other articles on this website and across the web, ERISA rules and regulations favor insurance companies, and it is easy to make a mistake in appealing a long term disability denial. That is why you should at least consider contacting an attorney if your claim has been denied or if your disability benefits have been terminated.

Don’t Let an Insurance Company Deny You the Security and Success You Deserve

If your disability insurance claim has been denied you should contact us right away. We will help you understand why your claim was denied and what you need to do moving forward. While there are no guarantees that the appeal of your claim will be approved on the first try, we will work diligently to help you prepare an appeal that is clear, concise, and complete with all necessary medical documents. We will keep you informed regarding the status of your claim for the duration of our attorney-client relationship, answering any questions you may have along the way.

Our job is to make the insurance company pay the benefits you are owed and maximize your recovery under your LTD policy. We never charge any attorney fees or costs unless we recover benefits for you. If your claim has been denied or terminated, contact us for a free consultation to discuss your long term disability claim.

Schedule a Free Consultation

Mr. Ortiz specializes in appealing long term disability claim denials. He understands how to communicate with the insurance company, the procedural requirements of the appeals process, and what kind of medical evidence you should include with your appeal letter. Call (888) 321-8131 for a free case evaluation.