How to Win a Long Term Disability Appeal: Do’s and Don’ts

If you’ve had a long term disability (LTD) claim denied, it’s natural to feel frustrated and overwhelmed. However, a claim denial isn’t the end of the road. You have the option to appeal, and many claimants successfully reverse denials through the appeals process.

Appealing the denial of a long term disability claim for benefits under the Employee Retirement Income Security Act (ERISA) is both a right and an obligation. This means you have the right to appeal a long term disability denial. However, under ERISA, you are also obligated to go through all mandatory appeals directly with the insurance company before you have the right to sue the insurance company in federal court for its failure to pay benefits.

Please note that because every claim is unique, this list of “Do’s and Don’ts” is not exhaustive. It serves merely as a reminder of the most important things you should and should not do during an appeal. We have another article that discusses how to appeal a long term disability denial in more detail. If you still have questions about how to file an appeal and what to include in it after reading these articles, you should consult a long term disability attorney.

Do’s: What You Should Do When Appealing a Disability Claim Denial

1. Submit a Complete Appeal: The administrative appeal process with the insurance company prior to litigation is critical. Every piece of evidence you intend to use in a lawsuit must have been part of the claim file during the appeal. Thus, your submission of evidence during the appeal process serves two important purposes. First, the insurance company may consider the new evidence and approve your claim, eliminating the need to sue them in court. Second, the evidence you provide during the appeal often becomes the only evidence you can use in federal court if your appeals are denied.
2. Tell Your Story: Personalize your appeal. Explain in detail why you’re unable to work, preferably in the form of an affidavit based on a detailed questionnaire about your daily life.
3. File an Appeal Within the Time Limits: If your LTD claim has been denied or your benefits have been terminated, you must file an appeal within the time limits specified in your LTD policy. In most cases, you have 180 days to file the appeal.
4. Confirm Receipt of Your Appeal: It is not uncommon for insurers to claim that they did not receive documents that were submitted to them. For this reason, we always submit appeal packages in a manner that provides proof of receipt. We typically submit appeals by mail, fax, and, if available, email.
5. Be Prepared for Surveillance: You should always be mindful of potential surveillance, but you should exercise extra caution if your insurer schedules you for an Independent Medical Examination (IME) or a Functional Capacity Evaluation (FCE). The insurance company will know your exact location and timing on the day of the evaluation. Since insurers often carry out surveillance over a span of three consecutive days, it’s advisable to remain vigilant not only on the day of the examination but also the day before and the day after. To minimize risks, consider having a friend or family member drive you to and from the examination, and aim to return directly home after the exam is completed.

Don’ts: What You Should NOT Do When Appealing a Disability Claim Denial

1. Submit Your Appeal Immediately: Although you may be outraged upon receipt of your denial or termination letter, you should not rush to submit a simple letter of appeal. Simply asking the insurer to reconsider is not sufficient. An incomplete or hastily prepared appeal is almost certain to be denied. Make sure you address all the reasons for the initial denial and provide ample evidence to support your claim.
2. Submit Your Appeal Before Reviewing Your Entire Claim File: Unless you’re on a tight deadline, you should request your entire claim file and policy from the insurance carrier. You will be surprised at all the information you will receive. The claim file should include your medical records, the insurance company adjuster’s internal notes and memos, medical reviews by the doctor hired by the insurance company, surveillance video (if any), and all other information the insurance company considered in deciding on your claim. You need to review this information, so you know what to emphasize or if there are any inaccuracies you need to address in your appeal.
3. Ignore the Vocational Aspect of Your Claim: Apart from your medical condition, consider how your disability impacts your ability to perform your job functions. If your role requires physical labor, provide evidence that shows you’re unable to meet these demands due to your disability.
4. “Appeal” or Discuss Your Case on the Phone: Do not attempt to request an appeal over the phone. You should not answer questions from the insurance company over the phone. You should request that all communications be in writing – and in traceable forms such as certified mail, fax, or email.
5. Handle Your Appeal Alone If You’re Not Physically or Mentally Capable: Consult an experienced attorney instead. You can hire an experienced attorney, often on a contingency fee basis, which means you only pay a fee if the lawyer obtains benefits for you.

By following these do’s and don’ts, you significantly improve your chances of winning your long term disability appeal. Always remember, when in doubt, consult an attorney to guide you through the complex appeal process.

If you’ve been denied long term disability benefits, the legal team at Ortiz Law Firm can help you cut through the red tape and fight for your benefits, no matter where you live in the United States. Give us a call today to discuss your claim at (888) 321-8131.