Administrative Appeals
Some LTD plans only require one appeal before you can file a lawsuit against the insurance company. Other LTD plans may require you to go through two levels of review of a denied disability claim to finish the plan’s claims process. Still, others require one appeal and make the second appeal optional (up to you to decide whether to bother with a second appeal). Just because you have the right to appeal, there may be reasons why you elect not to file an optional appeal and proceed directly to suing the insurance company. This is why you should discuss your legal rights with an experienced LTD attorney.
If two levels of review are required, the maximum time for each review may be less than the time limit permitted for one review. Thus, you should pay particular attention to your time limits to take action. If the insurance company continues to deny your claim for benefits after the first review, the plan must allow you a reasonable period of time to file for the second review.
If you are required to file two appeals before filing a lawsuit, you should continue to submit as much evidence as possible in the second appeal to support your claim.
Once the final decision on your claim is made, the plan administrator must send you a written explanation of the decision. The notice must be in plain language. It must include all the specific reasons for the denial of your claim on appeal, refer you to the plan provisions on which the decision is based, tell you if the plan has any additional voluntary levels of appeal, explain your right to receive documents that are relevant to your benefit claim free of charge, and describe your rights to seek judicial review of the plan’s decision in federal court.
Suing the Insurance Company in Court
If you have an individual policy or if you are a government or church employee, you can sue the insurance company in state court if the disability insurance carrier wrongfully denies or terminates your long term disability claim. You may not even have to file any appeals with the insurance company before suing the insurance company. The advantages of state court over federal court are numerous in disability claims. In state court, you have the right to a jury trial and you retain the right to have witnesses, to introduce new evidence, and to testify against the insurance company before a jury of your peers. You do not have the right to any of these things in a federal court ERISA claim.
If you have a group policy, your administrative appeals have been exhausted and you have followed all of the strict guidelines imposed by ERISA, then the next step would be to file a lawsuit in federal court arguing that the insurance company acted improperly in denying benefits. In such lawsuits involving employer-provided insurance plans, you are not entitled to a jury trial. You can only have a “bench” trial before a federal judge. Most claims are resolved in written briefs through cross-motions for summary judgment. ERISA allows judges to review the insurer’s denial for an “abuse of discretion” only.
In short, this legal term indicates that the judge’s ability to review and overturn or reject the decision being challenged is extremely limited. The judge will only look at the policy holder’s claim file with the insurance company in making a decision. As stated above, the claim file is maintained by the insurance company and contains all of the documents related to your insurance plan, claims, denials, and appeals. The judge will not consider any updated medical records since the last appeal, and new written statements or testimony from you or your doctors at a trial. The judge will have on “blinders” and will only consider what was before the claims handler in your claim file at the time the claims handler denied your claim.
Again – this is why providing as much supporting information as possible (doctor’s reports, letters from employers, letters from friends and family, etc.) during the administrative appeal review process is so important. Unless there is sufficient documentation in the file to support your claim, the judge may have to defer to the insurer or plan administrator’s reasoning for denying your claim.
Legal Representation in Long Term Disability Insurance Claims
Although based in Florida, the Ortiz Law Firm represents claimants across the United States. If your LTD claim has been wrongfully denied, delayed or terminated and you’d like to speak to an experienced Pensacola Long Term Disability Insurance Attorneys contact us at (866) 853-4512 to schedule a consultation. We can help you evaluate your claim to determine if you will be able to access Long Term Disability Benefits and how to move forward with the process.
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