Why Are You Given 180 Days to File a Long Term Disability Appeal?

Hi, I’m Nick Ortiz. I’m a board certified disability attorney in Florida. I’m licensed to practice in Florida and California, but I can handle a long term disability case anywhere in the country. Today, I want to talk to you about why are you given 180 days to file an appeal of a long term disability denial?

You’re given 180 days, by law, under ERISA, the Employee Retirement and Income Securities Act of 1974, so by law you’re given 180 days. And then you’ll see in a denial letter, typically at the very end of the letter the insurance company will say “If you disagree with our decision, then you must submit an appeal to us within 180 days.” But why so long? For most people, an appeal is simply writing them a letter saying, “Hey, we think you got it wrong, we want you to go back, take another look at it, and give a new decision.” But that will never work in terms of getting them to change their decision. You have to give them new evidence to get them to change their mind.

So I’m really gonna break down for you today everything that goes into an appeal, and why you might actually need a large part of that 180 days. And another reason why I’m doing this video is because we recently had a client who was really pushing us as to, he couldn’t understand why it was taking so long to get his decision out. And by so long, I mean approximately 60 to 90 days. And so part of this video is going to be to break it down for you, the audience and our clients, as to why we may need the entire 60, 90, 120, even up to 180 days to do an appeal.

So, first thing we do when we get a case is request the claim file. So, in your denial letter it will typically say, “You have the right to request a copy of your claim file.” That includes everything that’s been done in your case, all correspondence, it typically can be between 200 to over 1,000 pages long. It may include your insurance policy, communications to and from doctors, medical records, internal correspondence with the insurance company, but it has everything relating to your case. They have up to about 30 days to provide that to you. So once we get the claim file, let’s say that takes about 30 days, then we break it down and we try to determine what’s in the file. So we really need to determine what medical records are already in there so we can reverse engineer what medical records we need to obtain.

At the same time, while we’re waiting for the claim file to come in, we may send out a round of updated medical record requests to all the doctors to make sure that we have a complete set of medical records, ’cause the most important part of your case is your medical records. We try to do that at the same time as requesting the claim file so that both of those things are occurring simultaneously. Just as a side note, we used to request medical records after getting the claim file, but it was adding so much time that we decided to go ahead and start requesting them at the very beginning of the case. So, once we, and it takes doctors offices anywhere from a couple days to several weeks to process our records request, so again, that’s more time, typically 30 to 45 days to get all the medical records together.

Another thing that we do is we try to break down your insurance policy. So the insurance policy governs everything, and it determines what your rights and your responsibilities are. So we have to determine how they define the term disability, how they define the term occupation, we have to look at what your occupation is and what your duties and responsibilities are, so we really need to break down what it is you have to prove under your own individual policy so we can determine how to approach the appeal.

One of the other things that we need to do is determine whether or not we need to attack the vocational aspects of your case. That’s the job analysis in your case. So, they may have said in your letter that, “We think you could be a security guard, or a receptionist, or that you could work at an information booth handing out informational brochures.” So, we might need to have our own individual person hire what’s called a vocational expert, or job expert, to identify whether you could do those types of jobs, or any other jobs, given what they see in the medical records and based on any opinion evidence that’s provided by your doctors. So that’s another thing.

In addition to your actual medical records, we might need to obtain what we call opinion evidence from your doctors. You’re probably most familiar with this when the insurance company will send you what’s called an Attending Physician Statement. So the Attending Physician Statement is asking the doctor about what kind of limitations you have as a result of your medical conditions. And we’re gonna break the Attending Physician Statement down, a little bit more detail, in a companion video to this, and we’re gonna link it up below, so I do want you to watch a whole separate video that we have with respect to Attending Physician Statements, and how we do things a little bit differently. But with respect to the Attending Physician Statement, we don’t just like to use their generic one, we like to create a custom one with respect to your individual conditions. So it goes into a lot more detail trying to identify your specific limitations. So that take a little bit more time to communicate with your doctors and get that evidence together.

We also, in our office, will typically create an affidavit, which is your sworn statement which is evidence that can be used under penalty of perjury, it’s to be notarized, and that basically indicates what your limitations are from your own point of view. So we send you a very detailed questionnaire that breaks down what your limitations are on a daily basis so that we can use that to show why it is you can’t do work activity.

We get all this information together, then we have to do the legal analysis. So we have all of the evidence to be used, but then we have to break down the denial letter to determine what kind of legal errors we’re alleging that they made. So there’s some issue spotting trying to determine what the insurance company said, how it was improper and or illegal, or legally insufficient, and then attack each of the legal errors that they’ve made. So we combine the law with your facts, and we do a very detailed legal analysis of all the errors that we believe that they’ve made, and why we believe the decision should be overturned. And that in and of itself tends to be anywhere from 14 to 20 pages is the average length of our appeals. Where we’re summarizing all the medical, all the vocational, and all the legal analysis. So our appeal letters tend to be anywhere from 14 to 20 pages long.

This whole process, as you can tell from everything that I’ve said, can take on average, for our office, between 60 and 90 days. It could take even longer in some instances if we’re having trouble getting medical records and opinion evidence, it can be a little bit faster if there’s not as many doctors that we have to deal with. But that’s the average length of time that it takes. And I’m also trying to show you that there’s a lot that goes into filing an appeal.

So, if you would like to do this on your own, you can do it on your own, you’re not required to have an attorney to assist you, but if you do want the assistance of an experienced law firm like ours, then we do encourage you to give us a call. At 850-898-9904. If you’d like some more information, I also wrote a book called the Top 10 Mistakes That Will Destroy Your Long Term Disability Claim, I encourage you to download a free copy of this digital book at www.freeltdbook.com, we look forward to hearing from you.