If your long-term disability claim has been denied, you should not take “no” as the insurance company’s final answer. In most circumstances, you have the right to submit an appeal challenging the benefit denial; and if the appeal is unsuccessful, a wrongfully denied claim may be litigated in court.
What most people don’t realize, though, is that the pre-suit appeal may be their last opportunity to present evidence that a court will consider. Therefore, since a well-prepared appeal is critical to a successful outcome in court, the time to seek assistance is immediately after you receive a denial. Waiting until the appeal is denied to start looking for representation may be too late. An experienced representative will recognize what needs to be included with the appeal such as additional medical evidence or input from a vocational rehabilitation consultant.
Understanding ERISA rules
Employer-provided long-term disability plans are generally subject to a law known as the Employee Retirement Income Security Act of 1974 (ERISA). Under ERISA, a denied claimant must exhaust all internal appeals with the insurance company before filing a lawsuit in federal court. Strict time limits apply; and an appeal that is tardy by even a day may not be considered.
Many people don’t understand that their choices and actions during this stage can affect the viability of any lawsuit they ultimately file. Failure to submit necessary evidence during the claim appeal may prove fatal when the case gets to court. And a lack of understanding and familiarity with the intricate rules governing claim appeals can leave you at the mercy of the insurance company.
Stacking the claim file
Making sure the claim file contains all of the evidence necessary to convince an insurance company that your claim is meritorious is essential. While the ERISA claim and appeal process is not governed by the same evidentiary rules as apply in court, the claim file needs to be filled with as much evidence as possible that effectively rebuts the insurance company’s denial and convinces the insurer that benefits are due. And even after the appeal is submitted, newly adopted rules permit the claimant to review and respond to any adverse evidence developed during the course of the appeal before a final decision is issued. Failure to effectively challenge such evidence is likely to result in the denial being upheld.
Carefully planning an appeal and submitting any and all relevant documentation enhances the likelihood of victory in court since it gives the judge hearing the case the strongest and most convincing arguments to support an award of benefits. Such evidence might include:
- Treating physician records and reports
- Letters of support from friends and family
- Social Security records and reports
- Medical reports from specialists
- Medical journals or treatises
- Test results
- Functional testing or psychological testing in appropriate cases
- Videos and photographs
After an initial denial of a long-term disability claim, you usually have 180 days to file an appeal. Although that may seem like a long time, it is important to seek legal assistance from an attorney experienced in handling disability claim appeals as soon as possible. While a non-attorney advocate may be helpful, the advantage of choosing an attorney to handle your appeal is their ability to file suit on your behalf. The appeal process is an integral part of any litigation that ensues; and because appeals can involve complex medical, legal, and vocational issues, you need to have someone in your corner who understands and who has dealt with those issues in other appeals and in court.