When You Have Two Mandatory Appeals After An LTD 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 most policies 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. It is important to 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, which is all of the evidence that was in your claim file when the insurance company made its decision.

In some cases, you may be required to file only one appeal. In other cases, you are required to file one appeal, and you are offered an “optional” appeal. Occasionally, a claimant will have to file two mandatory appeals.

When you have two mandatory appeals, you will have two separate opportunities to (a) submit medical records to support your claim; (b) submit forms and/or letters from your treating physicians to support your claim; (c) poke holes in the insurance company’s “Peer Review” physician reports; (d) submit non-medical evidence in support of the claim (such as an affidavit or “day in the life” video; and (e) a legal brief outlining legal errors in the denial letter.

Please note that if you have two “mandatory” appeals available to you in the administrative review process directly with the insurance company, you will have to go through both of these reviews before you can go to court and file a lawsuit in your claim.

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 at (866) 853-7756 to discuss your claim.