Hi, I’m Nick Ortiz. I’m a board-certified disability insurance attorney. Today, I’m here to talk to you about whether you can file your own appeal in a long-term disability claim.
The short answer to that question is yes, you can file your own appeal, you do not need an attorney to file an appeal for you.
However, I will caution you that doing an appeal correctly is very time-consuming and very detail-oriented, and there are certain things that we like to see done, but I will go through some of those things with you today, and then tell you how we might be able to assist you.
So, I’m literally going to walk you through the various steps that a firm like ours will take when we’re evaluating and appealing a long-term disability claim denial.
First and foremost, is get the claim file. At the end of a denial letter, you will typically see language that says, “You are entitled to a free copy of your policy and your claim file,” if you simply write the insurance company at a designated address. So, that is step one is to get your whole claim file.
Number two is to index the file, which means go through it and determine what’s in there, and therefore, what needs to be obtained. But a key to that, also, is you need to have a familiarity with how to read an insurance policy, because in order to know what you need to do for your appeal, and what you need to do to prove up your case, you need to understand how to read an insurance policy to determine what it is that you need to do to establish what they call, “The proof of laws.”
What is your proof that you need to provide? What you will be surprised with, perhaps, is the fact they don’t have all your medical records, so, you need to update all your medical records, that’s obviously one of the key components to your case. There may be medical records that were requested, but never obtained.
Second, you might try to get additional opinion evidence from your doctors. That might be through the insurance company’s own attending physician statement forms that they use, or in a case like ours, we use custom forms for each individual case, tailored to the individual’s condition.
Next, you’re going to want to consider writing your own statement. We typically do an affidavit for our clients, which is a sworn statement that identifies what kind of problems that they have, what their functional impairments are, and how it limits their daily activities, ’cause that is gonna show what it is about their condition that keeps them from being able to do work activities.
Next, you need to look at the denial itself, and determine whether there are any legal errors in it, and again, that’s part of where we really help our clients, is identifying what are the legal mistakes that the insurance company made in denying your claim, because there are other cases that have come before you, where the case has gone to court, and the court has specifically identified the reasons why the insurance company’s decision was legally inaccurate, and it would be good to be able to analogize your case to those cases, to show that the insurance company in your case was acting, what we call, “arbitrarily and capriciously in denying your claim.”
So, the long and short is, can you do all of those things on your own? Yes, you could. I think the legal research part of it may be a little bit trickier, but again, it is all something that one could do.
We do typically recommend that you hire someone, not only because we know all those steps, and how to do those steps, and have the resources to take those steps, but also because of that very last part, which is identifying the legal issues in the case. But also, and perhaps even more important that that, is the issue of the ability or inability to introduce new evidence if your case is denied at the final stage with the insurance company, and need to go to court.
If your plan is a group plan, part of a group plan benefit, then your claim is subject to a federal regulation called “ERISA,” E-R-I-S-A. Under ERISA, you are not allowed to introduce any new evidence in court, if your case needs to go to court. In other words, you would be limited to arguing what’s in your claim file after your last appeal.
So, when we take on a case, where the client did all of their own appeals, we tell them, “Look, we are limited in what we can work with, with whatever evidence was submitted during your application and appeal process. We will not be allowed to introduce anything new, meaning I can’t get an opinion from your doctor, a statement from your doctor or your statement. I cannot introduce any new evidence.” I’m going to be, I call it in a way handcuffed, with whatever my client did before they came to see me, if they went through all of their appeals on their own, because we develop our cases in a very specific and detailed manner.
We prefer that we’re involved in the appeal process, so that we make sure that all the evidence we might need that goes into court, is admitted during the appeal process. So, for those reasons, we do very heavily recommend that you do contact an attorney to go through this process. However, again, you could do it on your own.
If you’d like to talk more about what our office can do to help you, we do handle cases nationwide, and I encourage you to give us a call at 850-898-9904. If you’d like additional written materials, I encourage you to download a free copy of a book that I wrote, called The Top Ten Mistakes that Will Destroy a Long-Term Disability Claim. You can obtain a copy of that book at www.freeltdbook.com. We look forward to hearing from you, have a good day.