Insurance providers routinely deny many of ERISA LTD claims. While some denials are legitimate, a disappointing number range from dubious to absurd. Unfortunately, insurance providers know that only some applicants will appeal their denial.
There are many common and understandable reasons people don’t appeal these rejections. Frequently, it’s simply a matter of not feeling up to a difficult and protracted legal battle while one is sick or injured. Others feel like they can’t afford the legal fees. There’s also an often false perception that insurance companies employ the most aggressive lawyers available, putting applicants in a David versus Goliath situation, no matter how convincing and meritorious their claim may be.
Let’s dispel some myths.
First Myth: Your case is doomed
As we explained above, some rejections can be heart-wrenching but valid. ERISA law is a convoluted, sometimes ridiculous quagmire that even some attorneys find baffling.
While the law is complex, it is frequently the so-called logic behind your denial which is difficult to understand, especially for a layman. It would be best to put aside your DIY spirit in these high-stakes situations. There’s nothing to lose by speaking to an attorney, and everything to gain. Many excellent disability lawyers will review your claim at no charge so that you get some guidance as to how to evaluate the issues presented. Any decent lawyer who knows this area of the law will tell you if your claim has validity. should be willing to But you’ll never know until you ask.
Second Myth: Claim denials are rarely overturned
Our blog wouldn’t exist without a steady stream of successful court decisions that started out as inexplicable application denials. All too often, insurance companies reject claims based on impossible catch-22 logic, lies, and even pure fiction. The law books are filled with valid claims that were initially denied by an insurance company only to be overturned on appeal. Insurers are incentivized to deny claims where they think they can justify it, even if those justifications turn out to be nonsense. But if you do not push back hard against these denials, you are giving the insurance company a win by default—something every insurer loves.
In short, if you feel like your provider is gaslighting you, then they’re probably gaslighting you.
Third Myth: Going to court will cost too much
Many ERISA attorneys work on contingency, but many do not. Contingency arrangements work where the lawyer believes the claim is valid and should be paid, but the client does not have the funds to hire the lawyer and pay by the hour. If a lawyer agrees to take a case on a contingency fee basis, it is because the lawyer expects to be successful in pursuing the claim. The downside of course is that sometimes giving up a percentage of your benefits to a lawyer by way of legal fees can cost the client more than it would if the client simply paid by the hour. But some clients have no choice, and they must ask for a contingency fee arrangement or do nothing at all. Each case is unique. The key is to ask the right questions, find out your options, and make intelligent choices.
Fourth Myth: The doctor reviewing your case for the insurance company independently determined that you are not disabled
Insurance companies often ask their internal doctors to assess cases in a medical field without adequate training in that field. Often, those doctors are not independent, and instead make more money providing expert opinions to the insurance company than they could make practicing medicine. These hired guns are used for a reason, and it is not necessarily to “get it right.”
If the denial of ERISA LTD benefits seems to defy logic, seek an attorney’s opinion. Do not accept “no” for an answer, unless you can understand and agree with the reasons behind that “no”.
Fifth Myth: Insurance companies know more than you do about the merits of your claim through the use of AI and other technology
Insurance companies are enthusiastically rolling out artificial intelligence tools to help them review the tide of applications for ERISA LTD benefits. Insurance companies tout the independence of these modalities and argue that they take the bias out of the claims process. WRONG! AI technology has so far proven incapable of effectively interpreting medical evaluations. Reliance on AI and other technologies is not intended to benefit anyone other than the insurance company. Simply because the claims evaluation is less expensive does not mean it is better or more accurate. If AI or other “advanced” technology played even a small role in the rejection of your ERISA LTD claim, you must consider an appeal, if only to have a human justify the denial.
It bears repeating: there’s nothing to lose by consulting a lawyer about an ERISA LTD denial. In the worst-case scenario, your situation remains unchanged. In the best-case scenario, you’ll receive the benefits you’re entitled to.