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Navigating the ERISA appeals process for long-term disability claims

On Behalf of | Aug 8, 2023 | ERISA

An unfortunate fact in the ERISA long-term disability world is that many people will find themselves appealing decisions which deny or terminate benefits. Whether the insurance company denied your initial application, or your benefits were cancelled later, you must steel yourself for a potentially protracted appeal.

There’s no need to rush an appeal (unless there is)

Benefits which are denied or terminated must be set forth in a letter from the insurance company. Receiving such a denial letter often sets off a minor panic. Those benefits may be your only financial lifeline and the possibility that they may never appear can be extremely stressful. The impulse is to race around, gathering more documentation, writing an appeal letter and getting everything in the mail as soon as possible.

In most cases, you will have 180 days to submit an administrative appeal. Unless they give you a shorter deadline, use that time to your advantage. You typically only have the right to one administrative appeal before things escalate to a courtroom; once in court, you will likely not be permitted to submit any new evidence which was not previously provided to the insurer during the administrative appeal. So, the administrative appeal process is typically where claims are won or lost. Insufficient or incomplete paperwork submitted during the administrative appeal is one of the most common reasons for long-term disability benefit denials, so thoroughness will be key.

Carefully go over the reasons for the denial and then make sure you meticulously address and rebut every one of those reasons in your appeal. The more new evidence you submit, the better. Simply resubmitting the same evidence will not help your case.

Contact your doctor and explain the situation and show the written termination or denial letter to the doctor, so they understand the issues and can provide you with additional supporting medical records, images, notes and anything else that might strengthen your case. You may even want to see a specialist who can fortify your general practitioner’s documentation.

It goes without saying that missing an appeal deadline can mean the end of your claim, no matter how strong it is.

If you don’t have it already, request a copy of your claim file

Under ERISA, insurance companies must provide claimants with a complete copy of their file. Reviewing this file may provide more insight into your benefits denial. Again, study any details that may have negatively affected your claim and then collect whatever evidence you can obtain to address and refute those points.

If you call the insurance company during the 180-day appeal window to request a copy of your file or ask questions, be clear that you will be submitting supplemental materials in support of your claim, after you have received and reviewed the claim file. Regardless, you must actually submit the appeal within 180 days of the denial or termination, or your appeal will be time-barred, so keep that deadline in mind at all times after the denial or termination–180 days can pass faster than you think!

Read (and reread) your policy

Insurance companies don’t write policies in a manner that’s easy for laymen to understand. They’re packed with jargon, legalese and longwinded explanations of otherwise straightforward topics. They can easily overwhelm or confuse casual readers. Take your time to unravel and understand every sentence. Highlight important passages and take notes. Most importantly, if you do not understand the policy, get advice from someone who does–do not guess at its meaning. The policy must be understood before you file your appeal.

While you should give the whole thing a careful read, the most important parts will be the definitions of disability in your policy. Take extra care with the sections that define “own occupation,” “any occupation,” exclusions and preexisting conditions. Note any limitation clauses, which often limit long-term disability benefits to 24 months for certain claim like psychiatric disabilities.

People suffering debilitating disabilities, particularly cognitive disabilities, may not have the capacity to absorb and retain lengthy insurance policy mumbo jumbo. If necessary, seek professional help to make sure you’re operating with the maximum amount of information.

Gather more evidence

If it seems applicable, you may want to undergo certain testing to better document your disability, like a Functional Capacity Evaluation or a Vocational Evaluation These tests can be expensive but can provide additional proof that your condition is severe enough to preclude you from working.

Write the best appeal possible

Again, you only get one administrative appeal, so make it count. If you’re anything less than supremely confident with your appeal, it’s in your best interest to consult an attorney before submitting it.

Consult an ERISA attorney

Long-term benefit denials are, sadly, increasingly common. Some denials are based on weak reasons or even no reason at all. Insurance companies know that a large number of people will not even try to appeal, so denial which are invalid will frequently never be challenged. There is very little downside for an insurance company to deny an ERISA claim and wait to see what (if anything) the claimant does.

Whether your denial seems insurmountable, or just incomprehensible, an ERISA attorney should be able to quickly decode the situation and give you an honest evaluation of your case and chances for a successful appeal. The tendency to be penny-wise and pound-foolish should be resisted. Given the high stakes involved, investing in the advice of a professional makes perfect sense, and can result in payment of substantial benefits.