Appealing LTD Denials with the Insurer: What the Insurer Won’t Tell You

 

You have been denied long term disability benefits by your employer-provided disability plan. Since it is an employer plan, it is governed by ERISA, the Employee Retirement and Income Security Act.  What do you do now?

 

The next step is that you must appeal the decision with the same company that just denied the claim.  The denial letter will state, near the end of the letter, that you have the right to appeal the denial with the plan.  But, the letter won’t tell you why it is important.  Why would you give them another chance when they did such a bad job on the initial denial?

 

• If you file a strong appeal, with specific detailed statements from your doctors, additional medical or vocational testing,

  and detailed specific arguments, you may get benefits without having to file suit.

 

o Many people handling appeals on their own will submit a single page letter from their doctor stating that the

   doctor believes the person to be disabled from their job.  You may think “How can the insurance company say

   the doctor is wrong when no one from the insurance company ever examined me?”  If all you do is argue the

   insurance company is wrong, and submit a simple letter, you are quite likely to lose your appeal.

 

o We are frequently successful in obtaining benefits for our clients through the internal appeal process. What the letter

   should contain is discussed briefly below and will be further discussed in another article.   An experienced ERISA

   attorney can be a big help in assembling a complete and convincing case that you are disabled from performing your

   job.  Everyone’s case is different and our past results don’t mean your appeal will be successful, but we win the vast

   majority of the appeals we bring.

 

• You must file the appeal if you ever want to sue the insurance company.

 

o If you try to sue without appealing, your case is quite likely to be thrown out by the court

 

o If your case is thrown out, it will likely be too late to file an appeal.  An experienced ERISA LTD attorney can be

   helpful in making sure you don’t miss any of the important dates.

 

• If you don’t file a strong appeal, you are likely to lose your lawsuit in federal court.

 

o  The court is likely to only review the materials the insurance company considered in making the initial benefit

    decision and any appeals.  For example, even if a neuro-psychological report would be useful to show that your

    thinking is too impaired to allow you to work, you are unlikely to be able to get the court to consider it unless you

    submit it during the appeal process.

 

o There are some exceptions to this rule, but they are limited, so you need to make sure everything is submitted

   during the appeal process.

 

• You may only have one appeal, so your first appeal has to be as strong as it can be.  Many plans allow a second

  appeal, but not all do.  If you don’t do a strong appeal at the first level, you won’t have the information you need to

  succeed in a later suit in federal court.

 

We will discuss what our appeal submissions consist of in another article on the web site.  But, it commonly includes the following: a letter, from six to twelve single-spaced pages, that I prepare setting forth in detail why the client is disabled and why the insurer is wrong; statements from the client’s doctors specifically refuting the medical basis for the denial; and oftentimes, reports and test results that we obtain specifically for the appeal, such as neuropsychological reports or functional capacity evaluations.

 

As you can see, your treating physicians are crucial to preparing a successful appeal.  We are lucky to be Fairfield County LTD attorneys, as our clients are frequently treated by nationally renowned specialists in their fields.   The Connecticut medical community is strong, which makes our Connecticut disability appeal practice much stronger.

 

When you first get the denial letter, and see what you believe to be the insurer’s ridiculous basis for denying benefits, you may think it will be easy to get the decision overturned.  But as you can see from this article, you have to make the best and most complete effort you can in every step of the appeal.  An ERISA attorney with long experience in long-term disability appeals can help make sure you do everything you can to get the benefits you have earned.

 

 

 

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