OPR Has Focused Exclusively on Disability Law for Over 30 Years
Independently document your symptoms, medication side effects, doctors’ visits, and general wellness as much as you can. Medical records often have errors or do not completely reflect what was discussed during your visits. Keeping your own log
Be truthful and thorough when you present your medical conditions, especially if you have co-morbid or multiple conditions.
Long Term Disability Appeals Process
Depending on the area of law governing your disability benefits, your appeal rights and responsibilities differ greatly. If you have a claim governed by State law (Bad Faith) and not ERISA, or you are unsure if ERISA applies to your claim, contact us to discuss and learn more about appealing.
If your disability policy is governed by ERISA, you have the right to appeal any “adverse benefit determination.” For most people, this means their monthly disability benefits have been denied or terminated. Under ERISA, it is important to understand that an adverse benefits determination generally includes any denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit. This means that even a reduction in your monthly disability benefits could trigger your right to appeal. Insurance companies do not always apprise you of this even though they are supposed to. If you are unsure about whether you should appeal, contact us to discuss your particular situation.
Under ERISA, you have 180 days from the date you were notified of the adverse benefits determination to submit an appeal. Appealing is mandatory if your claim is governed by ERISA. If you do not participate in the appeals process, you could forever lose your right to benefits and forfeit your right to benefits and forfeit your right to a lawsuit.
An appeal should not just be a letter explaining why you are disabled; it should include all credible documentation that supports your claim, taking into consideration the reasons for denial, policy language, and possible standard of review. The appeals process is critical to the strength of your case, and we advise you consult an attorney before submitting any appeals. Your first step should be to send written requests for documents and to thoroughly review all relevant documents of your claim. For more information on what to submit on appeal, go here.
Once your appeal is submitted, the insurance company or claims administrator has 45 days to make a determination. If special circumstances require, the insurance company may request an additional 45 days, for a total of 90 days, before making a determination. If the insurance company asks you for an independent medical examination or other testing after your appeal has been submitted, contact us before attending the testing.
Sometimes, insurance companies identify information it needs on appeal and uses that outstanding information as a reason to “toll” it’s timeline for rendering a decision on your appeal. Insurance companies often abuse the tolling rights and “special circumstances” statutory language set forth in ERISA. If you believe you have not received a timely determination, or that your claim is being improperly tolled on appeal for additional information, contact us to discuss your situation.
Appealing Disability Benefits Denials & Terminations:
Insurance Companies often deny otherwise valid STD and LTD claims in order to avoid the financial liability of having to pay benefits. Most disability insurance policies are “fully insured,” meaning that the insurance company administering claims is also responsible for paying the benefits on those claims. As you can imagine, this dual function creates a conflict of interest: the more claims are denied, the more money is kept in-house for the insurance company’s bottom line.
If you are facing a denial of your claim for short term or long term disability benefits, do not despair. You have 180 days to submit an appeal under ERISA, and appealing is mandatory. It’s important to know your obligations and rights, which vary depending on the law that governs your benefits.
What to Submit on Disability Policy Appeals
Just like each disability policy is unique, so is each appeal. In short, the purpose of your appeal is to “perfect” your claim, meaning you should address every reason for the insurance company’s denial and provide evidence to support your continued eligibility under the plan or policy. So how to best tackle your appeal depends on the particular facts of your claim denial. There is no “one size ts all” approach.
A strong appeal should include evidence to support your disabling conditions, rebut the insurance’s company’s reasons for denial, and expose the insurance company’s bias. Appeal letters do not have to contain argument, however having a highly experienced LTD attorney provide one to refute the insurance company’s reasons for denial with relevant law helps your appeal prevail.
What is most important on appeal is the evidence you submit, which is called the administrative record. When we represent clients on appeal, we often submit some or all of the following:
The evidence we submit is precisely gathered and prepared after careful review of your entire file and plan documents. We take pride in our tailored approach to representing you on appeal. We invest a tremendous amount of time in developing and executing a strategy that is designed to secure your benefits from the appeals process. If you’re claim has been denied, we provide expert service and advice as our rm is focused exclusively on disability benefits law. If your disability claim has been denied, get a free consultation with us before you submit your appeal.
Common Mistakes Made When Appealing Denials
Failing to send a written request for all relevant documents before appealing. claim is governed by ERISA, the insurance company has an obligation to provide you with a copy – free of charge – of all relevant documents before you submit an appeal. You cannot prepare an effective appeal without carefully reviewing and considering the relevant documents to your claim in the insurance company’s possession. If you need help sending a written request for relevant documents or have not timely received documents after requesting them, contact us today.
Appealing a denial based on emotion and not facts. It’s understandable that you are angry or frustrated at the insurance company’s denial. Undoubtedly, the denial letter contains inaccurate information about your conditions or treatment, misrepresents your doctors’ opinions, or outright lies about discussions you’ve had with your claims manager. It is tempting to submit an appeal in anger, but in doing so, you might overlook the inclusion of evidence important for refuting the insurance company’s denial. Contact us for experienced, compassionate representation.
Appealing in haste or too soon. To our horror, we have heard all too often of insurance companies denying claims and then encouraging claimants to “hurry up and submit an appeal.” To take this advice is to potentially ruin your chance at getting benefits because of the importance of appealing to cases governed by ERISA. While being without income is understandably difficult, and the reasons you should receive benefits is clear to you, do not forsake the appeals process.
Failing to provide all evidence that supports your claim. Perfecting your claim on appeal is a significant undertaking. Just like you were most likely uniquely qualified to perform your job, the Firm is uniquely qualified to do ours, which is to ensure you have all of the information necessary for appealing under the law. All too often, we see people want to appeal on their own, thinking, “how hard can it be?” And, after they are denied again, they are left with incomplete record, injuring their already difficult chances at litigation. Don’t make this mistake and regret it later.
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