If you insist on appealing on your own without legal representation, you should follow the steps below:
Read the entire denial letter carefully from start to finish. Read it again a couple more times. The insurance company is legally obligated to advise you of the specific reasons it is denying your claim. The carrier must reference the specific policy provision on which the denial is based; describe what additional material or information, if any, is necessary to further evaluate and support your claim; and explain what specific steps you must take to appeal.
Next, you should request your free copy of your claim file from the insurance company. Submit your request in writing immediately after the denial order to allow you sufficient time to review its contents before writing your appeal. This claim file should include a copy of your entire disability policy.
Is There a Time Limit to Appeal My Disability Denial?
Yes. A disability insurance claim is not like an automobile accident claim, where you may have years after the incident to file a lawsuit. Under ERISA rules and regulations, you only have 180 days from the date on the insurance company’s denial letter to file your appeal. It is critical that you give notice of your appeal before this deadline.
Note: Some long term disability policies provide for a second level appeal, and the deadline is often shorter than 180 days.
You should submit your appeal in writing, not by telephone, preferably by certified mail with delivery confirmation. It is critical that you do not miss your deadline. The time to appeal starts immediately after the insurance company denies your claim.
Your appeal letter should clearly state that you are appealing the denial of your disability claim. You should specifically state the basis for your appeal and list the additional evidence you are submitting in support of the claim.
If you received assistance in filing the appeal, be sure to mention this fact in your letter because insurance companies have been known to point to a well-written appeal letter by the claimant as support for upholding their previous denial. If preparing the appeal letter and putting together the enclosures took you a significant amount of time, be sure to mention that fact as well.
You Need Evidence to Support Your Appeal
Finally, do not assume that the insurance company obtained all of the medical records and other evidence relevant to your case. Carefully review the list of evidence the insurance company considered in rendering its decision and submit (or resubmit) anything that will help prove your disability. “Packing the record” with such evidence is critical. Don’t forget – in most cases, you cannot submit any additional evidence during the lawsuit, no matter how relevant it is to your case. The only thing the court will review is the information that was in the claim file at the time the insurance company made its decision. The appeals process is the perfect opportunity to add as much information as possible to the claim file. Such evidence may be critical to a lawsuit later down the line. For such reasons, I generally recommend that you do not handle your own appeal on your own. Remember- ERISA laws are unfair and difficult for non-attorneys to comprehend. For assistance with your appeal, call (866) 853-7210 as soon as possible.
Do I Have to File an Appeal in Every Case?
It all depends on how you obtained the policy. If the policy is through a private employer, employee organization, or union, then you may be required to go through the appeal process before going to court. If you have an individual policy or a policy provided by a government employer or church employer, then you may not be required to file any appeals before resorting to litigation. Because these rules can be very complicated, you should obtain a free consultation from an experienced disability attorney to explain to you your rights.
Why Is It So Important That I Appeal?
The Employee Retirement Income Security Act of 1974 (“ERISA”) requires you to exhaust your administrative remedies before you can file a lawsuit. The internal appeal process allows the insurance company an opportunity to correct its mistakes and avoid a lawsuit. If you do not give the insurance company the chance to right its own wrongs first, most courts will not allow your lawsuit to proceed. If you file a lawsuit without “exhausting” the internal appeals process, your claim will be dismissed. By the time your claim is dismissed in court, your internal appeal deadline with the insurance company might have already expired.
The internal appeals process is also a very important opportunity for you, the disabled claimant. It gives you a chance to load your claim file with information supporting your disability claim and to correct any misconceptions. It is imperative that you submit everything that may possibly help prove your disability and your credibility.
Should I File A Complaint with My State’s Department of Insurance?
If your claim is governed by federal ERISA regulations, then your state’s insurance laws are “pre-empted,” which means your state’s Department of Insurance has no jurisdiction. Many insurance companies do include stock language in their denial letters advising the denied claimant that he or she can file a complaint with his or her state’s Department of Insurance. This is in fact true. However, doing so is generally a waste of time. You will simply receive a response a few months later from the Department of Insurance saying that they lack jurisdiction in the matter. You will be no better off and your appeal deadline will be that much closer, if not already expired.
Oops. I Missed The 180-Day Appeal Deadline. What Do I Do Now?
You should not assume all is lost. You should immediately seek legal advice from an attorney like Mr. Ortiz who is experienced in handling ERISA disability cases to determine whether the typical 180-day deadlines apply to your claim.
How Long Does the Insurance Company Have to Make A Decision on My Appeal?
The insurance company has 45 days from the date of your appeal to make its decision. This can be extended by an additional 45 days if the insurance company requests an extension in writing within the first 45 days.
Unfortunately, disability insurance carriers do not make it easy for disabled claimants to receive the benefits that they deserve. If you are to work and you have been denied your long term disability benefits, the legal team at Ortiz Law Firm can help you cut through the red tape and fight for your disability benefits no matter where you live in the United States. Give us a call today to discuss your claim at (888) 321-8131.