When You Have One Mandatory and One Optional Appeal After a Denial or Termination of Benefits

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.”

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. You may be required to file only one appeal, or you may be required to file two appeals. Sometimes you are required to file one appeal, and you are offered an “optional” appeal. In our experience, Cigna LTD policies typically offer an optional appeal.

Why Would I File an Optional Appeal?

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.

When deciding whether you will file an optional appeal it is important to consider the evidence that has been submitted in support of your claim. If you have new office visit notes, a new statement from your treating physician, new diagnostic testing, etc., then it may be beneficial to file an optional appeal.

What are your options after your first appeal is denied where you have the right to one mandatory appeal and one “optional” appeal? You can either (a) file the optional appeal or (b) skip the optional appeal and sue the insurance company with a lawsuit in court. So which should you choose?

That really depends on the individual circumstances of the individual case. In some cases, it makes more sense to go through the optional appeal. For example, if there was not a definitive medical diagnosis through the first appeal and additional medical testing disclosed a more specific diagnosis, then a claimant may want to submit this new evidence during the optional appeal. Or, if a Social Security disability claim was approved after the first appeal, then the claimant may want to go through the optional appeal in order to submit evidence of the Social Security win.

However, if a claimant is tired of dealing directly with the insurance company, the claimant may decide to skip the optional administrative review step and go directly to Court. That way the claimant is no longer dealing with an insurance adjuster who appears bent on denying the claim and instead is asking the Court to step in and make the insurance company pay.

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 of 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.

What Will a Long Term Disability Attorney Do For Me?

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 while preparing to file a second appeal:

• Understand the reasoning behind the decision to uphold your long term disability claim denial.
• Gather new 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 updated 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.

While there are no guarantees that the appeal of your claim will be approved on the first try or even the second try, we will work diligently to help you file an appeal that is clear, concise, and complete with all necessary information.

Our job is to make the insurance company pay the benefits you are owed and maximize your recovery under your LTD policy. We never charge any attorney fees or costs unless we recover benefits for you. If your claim has been denied or terminated, 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 to discuss your claim at (866) 853-7756.