Dealing with a mental or physical injury or illness is exhausting and all-consuming by itself. Being denied long-term disability (LTD) insurance benefits by your insurer only makes matters worse. If your LTD benefits are denied, it is important for you to be familiar with the appeal process and to understand your legal rights. Your energy should be spent on treating your condition and getting better, not battling with your insurance company.
Under the Employee Retirement Income Security Act (ERISA), you have a legal right to appeal the wrongful denial or termination of disability benefits. Unfortunately, you have the burden and responsibility of proving your claim.
Managing an appeal on your own can be risky, especially if you have a severe physical or mental illness or injury. If you feel overwhelmed or that your case is too complicated to handle on your own, you should seek guidance from a legal professional.
You Need to Appeal Long-Term Disability Insurance Denial
Receiving a denial letter on your claim for long-term disability (“LTD”) can be a gut-wrenching, frightening, and frustrating experience. But now you must gather your bearings and fight the wrongful denial of your benefits.
If your LTD claim is part of a group plan through your employer, then it is likely governed by the Employee Retirement Income Security Act (ERISA). Not only do you have the right to appeal the unfavorable determination in your claim, you are often required to appeal the decision to protect your ability to file a lawsuit down the road.
The long-term disability appeal process begins after an LTD claim has been wrongfully denied or terminated. LTD claims are most often cut-off after 24 months when the definition of “total disability” under the policy changes from “own occupation” to “any occupation.”
In other instances, LTD claims have been terminated after the insurance company conducts video surveillance or sends the disability claimant for a Functional Capacity Evaluation (“FCE”). The FCE is usually conducted by a physical therapist, and such therapists almost always conclude that the claimant is not putting forth a good effort and that the claimant can work full time.
Internal Appeals May Be Required Before You Sue
If you have been denied benefits, you should review your insurance policy to determine what you must do to protect your rights. Specifically, you should determine how many times you are required to file an appeal with the insurance company before you are permitted to go to court.
You may be required to file only one appeal, or you may be required to file two appeals. Sometimes you are required to file one appeal, and you are offered an “optional” appeal.
You must know how many appeals you have because you need to know how many opportunities you have to submit medical evidence to support your claim for benefits. This is critical because you must “pack the administrative record” with all of the evidence you would want a court to review down the road in a lawsuit. That’s because the court’s review is limited to the administrative record, or all the evidence that was in your claim file when the insurance company made its decision.
The LTD Appeal Process
The first step you should seriously consider is contacting the Ortiz Law Firm by phone or by using the contact form on this website. You will have the opportunity to speak with a licensed attorney with substantial experience in handling long-term disability claims, appeals and lawsuits. Mr. Ortiz offers free consultations if your claim has been denied or terminated, and he will attempt to answer any questions you may have about the LTD Appeal Process. If we can help you, we will forward a contingency fee contract for your signature and an Authorization which will allow us to obtain a copy of your complete claim file from the insurance company.
Once you sign and return the above-referenced paperwork, we will request a copy of your claim file to determine what the insurance company relied upon in reaching its decision. Your claim file includes all of the medical records and reports that you submitted, a copy of the LTD policy, your application for LTD benefits, internal claim notes from the insurance company adjusters and all correspondence regarding your claim.
It usually takes 20-30 days for the insurance company to copy and forward a copy of your claim file to our office. Once your claim file arrives, it usually takes our team several days to several weeks (depending on the size of your file, which could exceed 1,000 pages) to scan the file and to organize and index the claim file. My office will then contact you to discuss the details of your LTD claim.
Mr. Ortiz will then outline your proposed appeal plan. With your input, we will then begin to follow through with the appeal plan.
It usually takes six to eight weeks to execute an appeal plan. It may take even longer depending on the factors such as the degree of cooperation we receive from your treating medical providers, and whether we are requesting an Independent Medical Examination or Vocational Rehabilitation Report. Once everything is gathered, the appeal letter is then filed, along with updated medical records and other supporting documentation.
Once the insurer receives your administrative appeal, the insurance company has 45 days after it receives the appeal letter in which to make its decision. This short deadline can be extended by an additional 45 days if the insurance company makes the request for extension in writing within the first 45 days of review. If the insurance company fails to meet the deadlines imposed by federal law, Mr. Ortiz will review your file with you and discuss whether filing suit immediately strengthens your legal position.
The LTD appeal process has two potential outcomes. Either your appeal is successful and a check is issued for past-due benefits and your claim is reinstated, or your appeal is denied and you have the right to file a lawsuit (unless the policy requires a second administrative appeal before filing a lawsuit).
When to Appeal
There are several key deadlines you must follow when you file a claim for disability insurance benefits:
- The deadline to file your claim.
- The final deadline to file your “proof of loss.”
- The deadline to file any administrative appeals with the insurance company before going to court. A couple key things to note here: the time to file an appeal depends on the language in your policy—typically between 60 and 180 days; and you may have the right to file several appeals, but you many not be required to file any appeals before filing a lawsuit in court.
- The time limit to file a lawsuit.
Because you may not be familiar with some of the deadlines that may apply to your claim, you should seriously consider consulting with an attorney to discuss your rights. Mr. Ortiz is familiar with all of the above deadlines and offers free consultations to disability claimants who have been denied or cut off from their benefits. He can be reached at 850-898-9904.