Anthem Disability Denials

With almost 40 million members, Anthem is one of the largest health insurance providers in the United States. Anthem sells a variety of health insurance products, including disability insurance for workers, often as a group benefits plan available to employers. Workers mistakenly believe that they will receive benefits if it is ever necessary to file a claim, but Anthem disability denials are much more common.

At Ortiz Law Firm, our disability attorneys help disabled workers fight for the disability insurance benefits they they are entitled to. We offer a free consultation after a claim is wrongfully denied or terminated so claimants can discuss the reasoning behind their disability denials with an attorney.

Anthem Blue Cross and Anthem Life Insurance Company

Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Empire BlueCross BlueShield, and Anthem Life are all part of one parent company, Anthem, Inc. Anthem is an independent licensee of Blue Cross and Blue Shield Association. Per Anthem’s website, Anthem Blue Cross and Blue Shield is the trade name of: 

• In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc.
• In Connecticut: Anthem Health Plans, Inc.
• In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.
• In Indiana and Ohio: Anthem Insurance Companies, Inc.; Community Insurance Company 
• In Kentucky: Anthem Health Plans of Kentucky, Inc.
• In Maine: Anthem Health Plans of Maine, Inc.
• In Missouri (excluding 30 counties in the Kansas City area): Healthy Alliance® Life Insurance Company (HALIC); Anthem Insurance Companies, Inc. (AICI) 
• In New Hampshire: Anthem Health Plans of New Hampshire, Inc.
• In Virginia: Anthem Health Plans of Virginia, Inc. and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. and its affiliated HMOs, HealthKeepers, Inc., Peninsula Health Care, Inc. and Priority Health Care, Inc.
• In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), Anthem Insurance Companies, Inc. (AICI), or, for former Atrium Health Plan members, Compcare Health Services Insurance Company. 

In California, Anthem Blue Cross is the trade name of Blue Cross of California and is offering short-term and long-term disability insurance benefits. While California does have a statutory disability plan (CA SDI), the state plan only replaces 55 percent of an employee’s income for up to 52 weeks.

Anthem Disability Insurance

Disability insurance protects policyholders from the loss of income resulting from an inability to work due to an accident injury or illness for an extended period of time. Anthem Life offers a variety of disability insurance plans to companies across the country, all of which are part of an employer-sponsored group benefits plan, and are governed by the Employee Retirement Income Security Act (ERISA). ERISA law is a federal law that heavily favors insurance companies over disabled individuals.

Anthem Short-Term Disability

As the name implies, short-term disability benefits from Anthem are only available for a short period of time. Many policies have a maximum benefit period of only 6 months, if not less. We have seen some short-term policies that will only pay benefits for 9 weeks. A short-term disability plan from Anthem would offer benefits on top of any state disability plan; however, many states do not have a disability plan.

Anthem Long-Term Disability

Anthem’s long-term disability plan extends short-term disability coverage for more complicated and longer-duration claims. Anthem typically replaces 60-66% of income and the length of time the policy pays out depends on which plan was selected. Depending on the coverage selected, a long-term disability insurance claim could be payable until you reach retirement age.

Anthem Long Term Disability Attorney

Many individuals who file a disability claim are shocked and dismayed by the hurdles placed in front of them by Anthem Life. The insurance adjuster requests more and more paperwork as part of the insurance company’s investigation into your claim. As soon as you think you’ve filled out the last form, you are given yet another one to fill out.

Your doctor may begin to get annoyed with Anthem’s phone calls to the doctor’s office and numerous requests for the doctor to also fill out paperwork. Then, after the investigation into the claim is finally finished, Anthem denies your disability insurance claim.

Policyholders are devastated when they are denied the very benefits they thought would be there to protect them if they ever became unable to work due to an injury or illness. Most are downright angry at their insurance carrier for their delay tactics and denials. That’s why it is important to have an experienced disability insurance attorney assist you by explaining to you the reasons for the disability insurance claim denial, and what you can do to fight back and win your claim.

At the Ortiz Law Firm, our experienced attorneys know how difficult it can be to deal with Anthem Life’s bad faith practices when you are fighting for long-term disability insurance benefits. Bad faith is a major problem that you may not even realize is impacting your claim. You have enough to deal with in treating your injury or illness. We also know how important these benefits are to you and your family when you are unable to work and earn an income.

Let us take on the burden of fighting the insurance company. With experience in dealing with Anthem Life and many other major insurance companies, our Anthem Life disability claim lawyers have the skills and knowledge needed to help you understand your rights under your policy in order to pursue the disability benefits you deserve.

Important Information about Anthem Disability Claims

Definition of “Disability” in an Anthem Insurance Policy

In order to receive disability benefits, you must meet the policies definition of disability. The term “Disability” is defined in each individual policy. Your definition may be different than the sample one below. You should always check your specific policy to see exactly how it defines the term “disability” for your long-term disability claim.

Here is an example of how the term is defined in a past policy to provide you some insight into how Anthem defines disability:

Disabled and Disability mean during the Elimination Period and the next 36 months because of Your Injury or Illness, all of the following are true:

You are unable to do the Material and Substantial Duties of Your Own-Occupation, and You are receiving Regular Care from a Physician for that Injury or Illness, and Your Disability Work Earnings, if any, are less than or equal to 80% of Your Indexed Monthly Earnings.

Thereafter, Disabled and Disability mean because of Your Injury or Illness all of the following are true:

You are unable to do the duties of any Gainful Occupation for which You are or may become reasonably qualified by education, training, or experience, and You are receiving Regular Care from a Physician for that Injury or Illness, and Your Disability Work Earnings, if any, are less than or equal to 60% of Your Indexed Monthly Earnings.

Pre-Existing Conditions and Anthem Disability Insurance

Even if you meet the definition of disability, Anthem Life will not approve your disability insurance claim if it determines that your disabling medical condition is pre-existing. The term “pre-existing” will also be defined in each individual policy. However, the policy excerpt below will help you to understand how the insurance carrier may define “pre-existing”, here is an example from one of its policies:

A pre-existing condition is an illness or injury for which you received treatment or where symptoms were present within 3 months prior to your effective date of coverage. A disability that begins in the first 12 months after your effective date will not be covered if it results from a pre-existing condition.

Appealing Anthem Disability Denials

At the end of the day, your insurance company exists to make money. For an insurance company, this means they need to collect more in premiums than they pay in claims. Having a good understanding of this basic premise will help you understand why even the most well-supported disability claims may be denied.

The most important thing is that you do not despair and give up just because you have received a a claim denial. ERISA law grants disability insurance claimants the right to appeal an unfavorable determination directly with the insurer through its internal appeals review process. Only after you have “exhausted” your appeals do you have the right to file an ERISA lawsuit.

Note: If you have an individual policy you purchased on your own (not a group plan), or if you are a government employee or member of a church plan, you may be exempt from ERISA regulations. If so, you have the right to file your lawsuit in state court. State law affords greater protection in disability claims to the consumer than an ERISA claim in federal court.

This is one of the many reasons why it is so important to hire an attorney. At the very least, you should schedule a free case evaluation so an expert can explain your legal options to you. 

A Disability Insurance Attorney Can Help With Your Claim

When filing a claim for LTD benefits or appealing a denial under an Anthem disability plan, the guidance of an experienced Anthem disability attorney can be extremely helpful and may even increase the chances that you will receive the benefits you are entitled to. We have experience with Anthem LTD claims and understands the difficulties of pursuing a claim for benefits. We have helped hundreds of clients with their disability insurance claims, and we would welcome the opportunity to put that experience to work for you.

We primarily represent clients during the administrative review appeal process, but can also help with lawsuits in state and federal court. Most of the claims we handle are for long-term, but we may also be able to help if you have been denied short-term disability benefits.

Legal Help in Getting Your Anthem Disability Claim Approved

Unfortunately, even claimants with the most severe disabilities and the best-prepared claims could receive a claim denial from Anthem. In the event that you receive a claim denial, you should be aware that you have the right to file an appeal. In the event that you have exhausted your appeals with the insurance company, you may have the right to file a lawsuit under the ERISA Act.

When appealing a denied claim for short-term disability or long-term disability benefits under a disability insurance plan, it can be helpful to have the assistance of an experienced lawyer. The Ortiz Law Firm has experienced disability attorneys and can help you obtain the benefits you deserve. Our firm offers detailed advice on the many issues related to the claims and appeals process, including:

• Helping you understand the reasons for your claim denial;
• Acquiring additional medical evidence, including medical records and other supporting documents to supplement the appeal;
• Completing the appeals paperwork;
• Preparing a legal argument to dispute the carrier’s decision to deny your claim
• Filing your appeal within the time limits allowed under applicable law;
• Filing an ERISA lawsuit in Federal Court; and/or
• Briefing your case for consideration by a federal judge during the ERISA litigation process.

You don’t have to face your battle against one of the largest health and disability insurance providers alone. The Ortiz Law Firm is here to help you with the appeal process. We will not give up on your claim until the denial is overturned and the insurer agrees to pay out your claim.

If you have been wrongfully denied by Anthem or if your claim has been terminated prematurely, call our office today at (888) 321-8131 to schedule a free consultation with an experienced Anthem disability claims lawyer. We would welcome the opportunity to discuss why your claim was denied and what we can do to help reverse the denial.