How Does an Attorney Help in the Long Term Disability Administrative Appeal Process?

I’m Nick Ortiz. I’m a board certified Disability Attorney in Florida. Today I want to talk to you about how does an attorney help in the administrative appeal of a long-term disability claim. This is really meant to be a companion video to the other video that we just recorded titled, “Why Are You Given 180 Days to File an Appeal?” So if you haven’t already seen that then I even encourage you to go watch that one first before watching this video and we’ll link that up below.

One of the big questions that I get is, “Well, can I just file this on my own?” And I always tell clients you’re not required to hire an attorney to assist you in your claim. You can file all of the appeals on your own. But, we do recommend that you hire somebody because there’s a lot more that goes into filing an appeal than most people think. And that’s what I want to break down for you today.

So first of all, you wanna make sure that you’re satisfying all your duties and responsibilities into making sure that your file is complete and giving them enough information, the insurance company, to make the right decision in your case. So, one of the first things that I get from a lot of clients is, “Well, I told him about all my doctors. “If they don’t have all my medical records, then that’s really their fault.” That’s problematic because at the end of the day, what we call The Burden of Proof is on you, the claimant. The Burden of Proof means that you the claimant have the burden of giving the insurance company all the information that it needs to make the right decision in your case. That means not only are you required to tell them where you’ve been, but if they’re having difficulty or if they’re not getting your medical records, it’s really on you to make sure that they have those records.

So you can tell them, “I gave you that information”, but at the end of the day, if they’re not given that information, you need to go out and get it and you need to make sure that they have it. And that’s one of the things that we do. When we get a claim file is often times we will find out that there’s a lot of missing medical records that need to be obtained and we’re gonna hunt those records down, track them down, make sure those doctors are giving them to us so that we can pas on the insurance company.

So that’s one of the biggest things is there’s often times missing records and our clients are shocked to discover that they may have identified five different doctors to the insurance company, and the insurance company was only able to get records from say two of them and therefore, we have additional records to track down. And sometimes just giving them that additional evidence is sufficient to satisfy that Burden of Proof and get them to pay benefits. So that’s one of the key things we do is make sure that you are satisfying your Burden of Proof.

Another thing that we need to do is make sure that we have the insurance policy because that really defines what the insurance company’s responsibilities are, but more importantly for our purpose is what you’re duties and responsibilities are. We have to look at how your policy defines different terms like disability and your occupation, own occupation, any occupation. We really have to look at what we have to prove in order to know what kind of evidence we need to generate and provide to the insurance company to get your claim approved. So for example, the term own occupation typically means that your are unable to do the material duties of whatever your job title is.

So if you’re a physician, or let’s say more specifically you’re a cardiologist, we’re going to want to try to define the job duties as a cardiologist within the physician field. We need to know that in great detail so that we know what type of other evidence we need to gather to show that you can’t do those job duties. Whether that’s medical evidence, opinion evidence from your own treating doctors, or vocational evidence from a job expert to show why it is, given your medical condition, you can’t perform those material duties. So there is a lot of legal analysis that goes into the insurance policy itself in making sure that we’re proving that per case.

The next thing is the vocational evidence of your case. So often times or in some instances we may want to hire our own vocational experts. So you may see in the record that they had a vocational person look at your file and they conclude that you can do certain job duties or job titles like being a Gate Guard at a private community, or you could sort laundry at a laundry facility or something like that. And then what we would do is maybe hire our own job expert to look at your file and then provide a report as to why it is you might not be able to do those things. So we have vocational experts that we work with in that regard.

We break down your file to make sure that we have sufficient opinion evidence. For example, the attending physician statement that is provided by the insurance company is really generic. It’s a two-page generic form and we’re gonna go into more detail in a companion video to this that we’re gonna link up below on attending physician statements, but in all of our cases, we create a custom form for our clients depending on their individual condition.

So if you have a heart condition, we have a cardiac questionnaire for the doctor. If you have a lumbar spine, or a back pain condition, we have a lumbar spine questionnaire. If you have a neck, we have a separate neck one from the back form. We have a fibromyalgia questionnaire. We have a lung questionnaire. We have a kidney questionnaire. We have a bilateral hip where if you have joint pain problems with your hips questionnaire. We have a leg questionnaire, shoulder questionnaire. We have questionnaires that are for lupus, rheumatoid arthritis, that are really tailored to all the different types of individual conditions.

And so we will customize a form for your condition to really pull out all the limitations you have as a result of your condition. So we’ll provide that to you to provide to your doctor to really maximize the chance of you winning your case because that, at the end of the day, is what we’re really trying to do. When you’re hiring an attorney, I guarantee to win your case but what we do is we help you have an opportunity to maximize your chance of winning your case.

So the next thing that we do is once we have all this information together we do a very detailed legal analysis. And this is where you really need an attorney. The attorney helps you identify what the legal errors are in their decision and then we do a legal analysis combining the facts of your case to the law. And we will even cite specific cases as to… And we will do a comparison between your case and other cases that I’ve gone through courts of law where the court ruled against the insurance company under certain fact patterns and we will show how the fact pattern of your case is very similar to that case and why the insurance company should change it’s decision because of the court decisions that has already been made. So we do have very detailed legal analysis of your case. And so that’s probably the most important part of your case. Now when we put this all together, our appeals tend to be anywhere from 14 to 20 pages long, whereas, most people who do their own appeal it’s one paragraph on one page. So we do do a very detailed analysis.

That’s our goal at the end of the day, is to try to get them to overturn the decision and pay you monthly benefits. That’s goal number one. And then goal number two is if they continue to deny you to litigate the case, take them to court and try to get you a recovery in court. And we’re successful in that way too. So we do encourage you to seriously consider hiring an attorney. I do believe that we could be of great assistance in helping you enforce your legal rights. And so we do encourage you to give us a call to discuss it a little bit further at (850) 898-9904. If you’re not quite ready to talk to someone, but you want even more information, then I do encourage you to download a free copy of an eBook that I wrote, called “The Top 10 Mistakes That Will “Destroy Your Long Term Disability Claim”. You can claim a free copy at We look forward to hearing from you