If your claim for short term disability, long term disability, or even life insurance claim has been denied, you are going to have to file an "appeal" before you can file a lawsuit.
The first step you should do is hire a lawyer now and one with experience! The insurance company has already denied your claim so stop trying to do it yourself. In practicing law for over 30 years in this area, I have only seen one non-lawyer appeal ever succeed, and only then for a couple of months before the insurance again denied the claim and cut off the money.
You must resist the urge to fire off a letter to the insurance company saying "I appeal." That type of appeal rarely works, if ever and the lawsuit that you will have to file later will be very weak.
Basically, what the insurance company doesn't tell you is that the "appeal" is the whole case—it's the record, absent a few exceptions, that the Court will review later on. You can't hold back any of your evidence and you need to know what the insurance company based its denial on so that you can counter it. The purpose of an appeal is to allow you to comment on the information that the insurance company has gathered as well as present any new evidence that would help your claim.
If you’ve had a long-term disability claim, short-term disability, or life insurance claim denied in Alabama, Georgia, or Florida, we can help with the appeal or with your lawsuit if the appeal is denied.
Federal Law and Long-Term Disability Policies
LTD policies are often obtained through your employer, There can be a difference in how policies are administered, especially in the appeals process, depending on where it was obtained – through your employer or on your own.
Most employer-sponsored LTD policies are covered by a federal statute known as the Employee Retirement Income Security Act (ERISA). The way to determine if your policy is covered by ERISA is by reading the Summary Plan Description (SPD) that your employer is obligated to provide when you sign up for coverage. You can also check with us if you’re unsure. In very few instances, some employers will state that your claim is governed by ERISA when it's not. Usually, this works in your favor, but call us if you're unsure, or need help in determining whether ERISA applies to your claim.
Under ERISA, you have 180 days to file an appeal after you receive a denial letter from your insurer. The possibility for a second appeal also exists. Ultimately, if your appeal fails, you can then file a lawsuit but with only a few exceptions, you can't skip the "appeal" and go straight to filing suit. If you skip the appeal phase in an ERISA case, the most likely result is that your case will get dismissed and then the appeal time will have run out. Unfortunately at that point, you will be left without having filed a timely appeal (the insurance company will deny your claim based on that reason alone) and no lawsuit to proceed with.
Common Reasons Cited for Denials
The most common reason cited in denial letters is lack of sufficient medical evidence. Insurers often come up with other reasons, claiming you missed a deadline or failed to respond to a request for additional information, but medical reasons are usually central.
Filing a disability claim is something best done with the help of an experienced attorney. With the assistance of a legal team, you should include with your claim application as much supporting evidence as possible. You should make available all pertinent medical records, including X-Rays, MRIs, test results, and anything that backs up the condition that is the basis for your disability claim. The more details, the better.
In addition, first-hand testimony by family and friends can help as well. If your spouse can attest to how he or she has to help you in and out of bed each day, or perform other tasks for you that a normal person should be able to perform on their own, that can help solidify your claim.
Your Right to Appeal a Denial
Under ERISA, you must pursue at least one appeal before you can file a lawsuit, and the appeal must be filed within 180 days following receipt of your denial letter. Your appeal must be reviewed by someone at the insurance company other than the person who denied your initial claim. The insurer has 45 days to make a decision, but if need be, can extend the period by informing you of “special circumstances” requiring an extension and that extension can last anywhere up to 90 days and sometimes longer.
If your appeal is denied, the insurer must provide a detailed explanation for the denial, including why and how they disagreed with the medical or vocational expert opinion submitted with your claim. Under ERISA, the insurance company is allowed to establish a time frame in which you can file a lawsuit following the denial of your appeal. It could be anywhere from six months to a year, but it must be stated in the appeal denial letter.
If your plan is not covered by ERISA, it probably still has an appeals process in place, and you should consult an experienced insurance/ERISA attorney to determine whether you should appeal anyway. Contact us to review your options.
How Legal Counsel Can Help
You should always begin your disability benefit claim by working with a skilled attorney who can help you assemble and present overriding proof of your medical condition. If you merely fill out a claims form on your own and attach a brief physician’s note, the odds are that the insurer will come back to you for additional documentation. If you fail to provide that, or provide just cursory responses, you’re probably looking at a denial.
R Willson Jenkins PC: Experience You Can Trust
Don’t face your insurance company alone. The claims adjusters they employ are out to protect the company’s bottom line, and they’ll look for every reason they can to lowball or deny your claim. Get us involved from the start. We know how insurance adjusters operate, and we can handle their questions and additional demands.
We will also work with your doctor and other medical and vocational specialists to assemble a complete supporting package for your application or your appeal. We have a proven success record with ERISA claims and lawsuits for over 30 years. Contact R Willson Jenkins PC with your LTD issues.