The long-term disability appeal process starts after your insurance company denies or terminates your long term disability claim. Benefits are frequently terminated after benefits have been payable for 24 months. For most policies, this is when the definition of “total disability” transitions from “own occupation” to “any occupation.”
In other instances, LTD claims are cut off after the insurer conducts video surveillance or sends the disability claimant for a Functional Capacity Evaluation (“FCE”). The medical professional conducting the evaluation almost always concludes that the claimant is not putting forth a good effort and can work full time.
Regardless of when it happens, receiving a denial letter for your long term disability claim is a gut-wrenching, frightening, and frustrating experience. But do not give up – now is the time to fight back against the wrongful denial of your claim.
An Internal Appeal May Be Required Before You Sue
After a denial you need to review your insurance policy to determine what your appeal rights are. Specifically, you should determine how many administrative appeals you have the right to file a lawsuit. 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.
It is also critical that you know exactly how many appeals you are permitted to file. This is because you need to know how many opportunities you have to submit evidence in support of your disability claim. The court’s review is limited to the evidence in your file when the final administrative denial was issued, so it is critical that you “stack the record” with as much supporting evidence as you can. Some of the evidence that you should consider filing with your appeal is set out in the next section
How Will a Disability Attorney Help With My Appeal?
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. 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).
There are a few critical deadlines you must meet:
- The deadline to submit your claim.
- The final deadline to provide “proof of loss.”
- The appeal deadline. Note: Your specific appeal deadline is stated in your disability insurance policy. Typically, you have between 60 and 180 days.
- The deadline 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. Ortiz Law Firm can help you navigate through the appeals process and recover the benefits you deserve. We are based in Florida, but we handle disability claims nationwide. Give us a call today at (888) 321-8131 to discuss your claim.