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

If your insurance carrier has denied or terminated your long term disability claim, you should review your insurance policy to familiarize yourself with your appeal rights and requirements. Specifically, you should determine how many appeals you have the right to and/or are required to file before you can file a lawsuit against your insurer. Under the terms of most policies, you are only required to file one appeal. However, there are some policies that require you to file two appeals. There are also policies that only require one appeal, but you are also offered an “optional” appeal.

Why Would I File an Optional Appeal?

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.

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. It is critical that you “stack the record” with as much evidence as possible before you file a lawsuit. In most cases, the court will be limited to reviewing the same evidence that was available for the insurer to review.

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.

Understanding Key Deadlines

There are a few critical deadlines you must adhere to during the long term disability claim process. Here’s a brief rundown of the deadlines:

1. The deadline for your initial claim submission.
2. The deadline for submitting your “proof of loss.”
3. The administrative appeal deadlines.  Your appeal deadlines depend on the terms of your policy, but typically you have 60 to 180 days. 
4. The time limit for filing a lawsuit.

How Can a Long Term Disability Attorney Help?

Mr. Ortiz and his team provide guidance and support to clients throughout the appeals process. Here are some of the specific steps they will take as they prepare your appeal:

1. Understand the rationale for upholding your long term disability claim denial.
2. Compile fresh evidence that could strengthen your case, such as witness testimonies, medical records, physician’s opinions, employment data, and vocational assessments.
3. Request, scrutinize, and analyze your claim file to identify what medical and other documentary evidence exists.
4. Request, scrutinize, and analyze your insurance policy to clarify the interpretation of crucial terms and identify all available coverage.
5. Conduct a thorough evaluation to determine what needs to be proven to qualify for benefits under the LTD insurance policy.
6. Examine legal issues, such as the burden of proof, and determine whether state or federal law applies.
7. Obtain a sworn statement from your physicians to gain a comprehensive understanding of your condition, the resulting limitations, and prognosis.

While there’s no guarantee that your appeal will be successful on the first or even the second attempt, we are committed to preparing an appeal that is precise, clear, and replete with all necessary data. Our mission is to ensure that the insurance company fulfills its obligation by paying the benefits you are entitled to and maximizing your recovery under your LTD policy.

We don’t charge attorney fees or costs unless we secure benefits for you. If your claim has been denied or terminated, the legal experts at Ortiz Law Firm are prepared to assist you in navigating bureaucratic complexities and advocating for your disability benefits. We represent claimants located anywhere in the United States. Contact us at (888) 321-8131 to discuss your claim today.