When most people file a long term disability appeal it is a really basic, one or two paragraph appeal letter that basically says,
“Look, long term disability insurance company. I really think you got this one wrong. I think there is more than enough evidence to support my long term disability claim. I want you to go back, take another look at my claim file, and I think you will see that there’s enough evidence to approve my claim for disability benefits. So, I hereby appeal. Go back and take another look at it.”
Now, that is wholly insufficient.
The Insurance Carrier’s Internal Appeal Process
The insurance company wants to show that they’re taking a good, hard look at your long term disability appeal, so they assign your claim file to a different adjuster that wasn’t involved in the initial long term disability denial. In essence, it’s as if they’re taking your case from Susie’s desk and they’re putting it on Janet’s desk along with your disability appeal letter, and they’re saying, “Hey Janet, did Susie get it right? Do you agree with her denial letter?”
Well, what do you think that Janet’s going to do? Nine times out of ten she’s going to say, “Yes, my colleague, Susie, got it right. The appeal letter did not change the previous long term disability denial” This is especially true if you have not provided any new medical evidence which they can use to overturn the previous denial. If your claim was denied, your disability appeal letter has to give the insurance company something new in the way of medical evidence or other opinion evidence to get them to change their mind.
Our Process for Appealing a Long Term Disability Denial
When we prepare a disability appeal, the first thing that we do is request a copy of your insurance policy to determine what your rights and responsibilities are in terms of proving up your case. We also request an entire copy of your claim file, then we take that claim file, break it down, and we reverse engineer it to determine what medical evidence we need to provide to the insurance company. That way we can work with you to strategize and get updated medical records and, perhaps, forms or letters from your doctors to address the reasons stated in the denial letter as to why the insurance company denied your claim. If you see multiple doctors, we’ll try to obtain a statement from each one.
We also work with you to obtain your statement, typically in the form of an affidavit, or what we call a sworn statement. In the statement, we identify what your impairments and resulting limitations are. The statement is additional evidence that we can submit with your disability appeal to show the insurance company why you can’t do your job and new evidence that may get the insurance company to change its mind.
Finally, we do a comprehensive legal analysis, where we take the reasons why the insurance company denied your claim, which should be set forth in the denial letter, and we show why their reasons are insufficient as a matter of law. We may site legal cases to compare your claim to others where the insurance companies may have made similar mistakes in the past.
Just to give you an idea, our long term disability appeal letters tend to be anywhere from 16 to 20 pages long, summarize all your medical records, all the opinion evidence, and all the legal reasons why we think their decision is insufficient and the claim should be approved. That’s a lot different than a simple one or two-paragraph appeal.
We discuss writing an appeal letter in more detail in another article titled How to Write an Effective Long Term Disability Appeal Letter.
If the appeals process is overwhelming you can hire a long term disability attorney to prepare the appeal letter for you. Most disability attorneys, including those at the Ortiz Law Firm, operate on a contingency fee basis, meaning we only get paid if there is a recovery. There are no up-front costs or fees, so you can get the help you need during this time of financial difficulty.
If you’d like to talk to an experienced attorney who might help walk you through this process, then I encourage you to give us a call. I’ve also written a book about long term disability cases. It’s called the Top 10 Mistakes That Will Destroy Your Long Term Disability Claim, and it is available to download for free.