When Only One Appeal is Available After a Denial

The long-term disability appeal process begins after an LTD claim has been wrongfully denied or terminated. LTD claims are most often cut-off after 24 months when the definition of “total disability” under the policy changes from “own occupation” to “any occupation.”

In other instances, LTD claims have been terminated after the insurance company conducts video surveillance or sends the disability claimant for a Functional Capacity Evaluation (“FCE”). The FCE is usually conducted by a physical therapist, and such therapists almost always conclude that the claimant is not putting forth a good effort and that the claimant can work full time.

Receiving a denial letter on your claim for long-term disability (“LTD”) can be a gut-wrenching, frightening, and frustrating experience. But now you must gather your bearings and fight the wrongful denial of your benefits.

An Internal Appeal May Be Required Before You Sue

If you have been denied benefits, you should review your insurance policy to determine what you must do to protect your rights. Specifically, you should determine how many times you are required to file an appeal with the insurance company before you are permitted to go to court.

If your LTD claim is part of a group plan through your employer, then it is likely governed by the Employee Retirement Income Security Act (ERISA). Not only do you have the right to appeal the unfavorable determination in your claim, you are often required to appeal the decision to protect your ability to file a lawsuit down the road.

Managing an appeal on your own can be risky, especially if you have a severe physical or mental illness or injury. If you feel overwhelmed or that your case is too complicated to handle on your own, you should seek guidance from a legal professional.

You may be required to file only one appeal, but you must know how many appeals you have because you need to know how many opportunities you have to submit medical evidence to support your claim for benefits. This is critical because you must “pack the administrative record” with all of the evidence you would want a court to review down the road in a lawsuit. That’s because the court’s review is limited to the administrative record or all the evidence that was in your claim file when the insurance company made its decision.

Some of the evidence that you should consider filing with your appeal is set out in the next section “What Will A Long-Term Disability Attorney Do For You?”

What Will a Long-Term Disability Attorney Do For You?

Mr. Ortiz and his staff offer detailed advice to clients throughout the appeals process. Here are the most important things he will do in your case:

• Conduct the initial interview with the client.
• Advise the client about long-term disability claims.
• Gather documentary evidence that may be used in the case, including witness statements, medical records, medical opinions from your doctors, employment information, and vocational assessments.
• Request, review, and analyze the client’s entire claim file to determine what medical and other documentary evidence is in the file.
• Request, review, and analyze the client’s insurance policy to determine the definitions of key terms in the policy and to determine what coverages are available under the policy.
• Conduct a detailed evaluation to determine what must be proven to receive benefits under the LTD insurance policy.
• Analyze the legal issues, such as the burden of proof, and whether state or federal law applies.
• Take a sworn statement from the client’s physicians or treating providers to fully understand the client’s condition, resulting limitations, and prognosis.

Once the insurer receives your administrative appeal, the insurance company has 45 days after it receives the appeal letter in which to make its decision. This short deadline can be extended by an additional 45 days if the insurance company makes the request for extension in writing within the first 45 days of review. If the insurance company fails to meet the deadlines imposed by federal law, Mr. Ortiz will review your file with you and discuss whether filing suit immediately strengthens your legal position.

The LTD appeal process has two potential outcomes. Either your appeal is successful and a check is issued for past-due benefits and your claim is reinstated, or your appeal is denied and you have the right to file a lawsuit (unless the policy offers a second optional appeal or requires a second administrative appeal before filing a lawsuit).

When to Appeal

There are several key deadlines you must follow when you file a claim for disability insurance benefits:

• The deadline to file your claim.
• The final deadline to file your “proof of loss.”
• The deadline to file any administrative appeals with the insurance company before going to court. A couple key things to note here: the time to file an appeal depends on the language in your policy—typically between 60 and 180 days; and you may have the right to file several appeals, but you may not be required to file any appeals before filing a lawsuit in court.
• The time limit to file a lawsuit.

Because you may not be familiar with some of the deadlines that may apply to your claim, you should seriously consider consulting with an attorney to discuss your rights. 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 at (866) 853-7756 to discuss your claim.