When a long term disability claim is wrongfully denied or terminated most claimants are required to file at least one appeal. In this article, we will discuss why most appeals suck, our process to prepare for the appeal, and how to write a long-term disability appeal letter if you decide to move forward without an attorney.
Why Most Long Term Disability Appeals Suck!
When most people file a long term disability appeal it is a really basic, one or two paragraph appeal letter that basically says,
“Look, long term disability insurance company. I really think you got this one wrong. I think there is more than enough evidence to support my long term disability claim. I want you to go back, take another look at my claim file, and I think you will see that there’s enough evidence to approve my claim for disability benefits. So, I hereby appeal, go back and take another look at it.”
Now, that is a wholly insufficient long term disability appeal.
The insurance company wants to show that they’re taking a good, hard look at your long term disability appeal, so they assign your claim file to a different adjuster that wasn’t involved in the initial long term disability denial. In essence, it’s as if they’re taking your case from Susie’s desk and they’re putting it on Janet’s desk along with your disability appeal letter, and they’re saying, “Hey Janet, did Susie get it right? Do you agree with her denial letter?”
Well, what do you think that Janet’s going to do? Nine times out of ten she’s going to say, “Yes, my colleague, Susie, got it right. The appeal letter did not change the previous long term disability denial” This is especially true if you have not provided any new medical evidence which they can use to overturn the previous denial. If your claim was denied, your disability appeal letter has to give the insurance company something new in the way of medical evidence or other opinion evidence to get them to change their mind.
How to Write a Long Term Disability Appeal Letter: Our Process
When we prepare a disability appeal, the first thing that we do is request a copy of your insurance policy to determine what your rights and responsibilities are in terms of proving up your case. We also request an entire copy of your claim file, then we take that claim file, break it down, and we reverse engineer it to determine what medical evidence we need to provide to the insurance company. That way we can work with you to strategize and get updated medical records and, perhaps, forms or letters from your doctors to address the reasons stated in the denial letter as to why the insurance company denied your claim. If you see multiple doctors, we’ll try to obtain a statement from each one. Here is a breakdown of our process to prepare for an appeal:
We also work with you to obtain your statement, typically in the form of an affidavit, or what we call a sworn statement. In the statement, we identify what your impairments and resulting limitations are. The statement is additional evidence that we can submit with your disability appeal to show the insurance company why you can’t do your job and new evidence that may get the insurance company to change its mind.
Finally, we do a comprehensive legal analysis, where we take the reasons why the insurance company denied your claim, which should be set forth in the denial letter, and we show why their reasons are insufficient as a matter of law. We may site legal cases to compare your claim to others where the insurance companies may have made similar mistakes in the past.
Just to give you an idea, our long term disability appeal letters tend to be anywhere from 16 to 20 pages long, summarize all your medical records, all the opinion evidence, and all the legal reasons why we think their decision is insufficient and the claim should be approved. That’s a lot different than a simple one or two-paragraph appeal.
If the appeals process is overwhelming you can hire a long term disability attorney to prepare the appeal letter for you. Most disability attorneys, including those at the Ortiz Law Firm, operate on a contingency fee basis, meaning we only get paid if there is a recovery. There are no up-front costs or fees, so you can get the help you need during this time of financial difficulty.
How To Write a Long Term Disability Appeal Letter
Your long term disability appeal should be in writing and clear as to its intent. For example, you may start your appeal 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 medical evidence the claims handler will find in your appeal packet that will change the denial into an approval.
Remember: any information you fail to submit with your disability appeal may never be heard or considered by a court of law in a lawsuit, or litigation. If your appeal is denied, you may not have another opportunity to submit new evidence. You should carefully consider all of the information you would like to include with your disability appeal letter before sending it to the insurance company via certified mail, fax, or e-mail. You can find the contact information to which you must submit your appeal letter in your long term disability claim denial letter.
Medical Evidence to Support Your Long Term Disability Appeal
Your appeal should include updated medical evidence and physicians’ opinions as to your limitations, all of which should work to satisfy the disability policy and plan’s definition of disability. Review your long term disability claim file and determine if any of your medical records are missing. Missing records could be the reason your claim was denied in the first place, so you should identify and obtain any medical records that are not in your claim file.
Your doctors’ opinions may be in the form of a narrative statement or a Residual Functional Capacity form or a Medical Source Statement. You should not rely upon your claims handler to draw an accurate conclusion about how your condition impairs your ability to work solely from the medical records alone. Instead, you should ask your doctor to thoroughly explain in writing how your medical conditions impair your ability to perform work activities or even routine activities of daily living. Submit this form with your long term disability appeal letter and it will create a clearer picture of the difficulties you are having and why you are not able to sustain competitive employment.
You may also document the side effects of the medical treatment itself and how negative side effects impair your ability to work in your appeal. For example, you may be taking medications that have a very heavy sedative effect making it impossible for you to stay awake. What you do to treat your medical conditions can have just as much of an effect on your ability to perform work activities as the sickness or injury itself. As such, make sure you and your doctors identify any medications you are taking or treatments you are undergoing, as well as the side effects from the same.
Note: You should not limit yourself to written reports solely from your primary care physician. Although you will likely have one main family doctor who treats you for your overall health, you might also have had treatment from specialists for certain conditions. Ask for support of your disability claim from these specialists as well. The more medical evidence you have and the more doctors you have to identify your limitations and restrictions, the stronger your long term disability claim becomes.
Non-Medical Evidence to Support Your Long Term Disability Appeal
You can also get statements from people other than your medical doctor to support your disability claim. For example, if you suffer from a sickness (as opposed to an acute injury), your employer certainly should have some knowledge that something changed over time that caused you to be unable to work. You could, therefore, obtain written support from your employer about your dwindling performance. You should also request a copy of your personnel file. This type of information may show a history of good performance reviews, with the only negative reviews coming towards the end of your employment.
Who else can you think of? Brainstorm! Keep the evidentiary support going. Obtain written statements from friends and family in your personal life. While they may not be medical experts, a spouse, pastor, family member, close friend, or former co-worker can all provide excellent insight into the struggles you face on a daily basis. You can support your long term disability appeal with third-party statements regarding changes to your daily activities, social life, etc.
You may also consider submitting a professional vocational assessment, or an evaluation from a “job expert”, of why you cannot work with your medical impairments. This can be especially helpful if the insurance company obtained a vocational assessment as part of its review that led to the denial of your claim. The expert hired by the insurance company is supposed to be an impartial expert, that is rarely the case when they are relying on the insurance company for a paycheck.
Legal Representation for Your Long Term Disability Appeal
Although based in Florida, the Ortiz Law Firm represents disability insurance claimants across the United States. If your long term disability claim has been wrongfully denied, delayed, or terminated, and you’d like to speak to an experienced long term disability attorney, call us at (888) 321-8131 to schedule a consultation. We can help you evaluate your claim to determine how to move forward with the long term disability insurance appeal process.
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