You’ve submitted a comprehensive claim to your insurance company for Long Term Disability benefits. You have your treating doctor’s support and you complied with all of the insurance company’s requests. Because you are clearly disabled, you thought your claim would be approved without a problem. However, after waiting patiently for a couple of months, you receive a denial letter in the mail. Naturally, you are shocked and dismayed. Your initial reaction is to call the insurance company to complain and to demand an explanation for the adverse decision. But you should avoid acting impulsively.
If your disability insurance claim is governed by the Employee Retirement Income Security Act (“ERISA”), you will be given 180-days (roughly six months) to submit an administrative appeal to the insurance company. While you do not have wait the full six months, don’t rush to submit your disability appeal. Take your time, and submit a comprehensive appeal designed to convince the insurance company to change its determination. Keep in mind that you may not get another chance to submit additional information to the insurer if your appeal is denied.
Here are some of the steps we take when helping a client with an administrative appeal of a denied Long Term Disability claim:
1. We Request and Review a Copy of Your Claim File. Your claim file consists of, among other things, all the documents you submitted and the insurance company gathered during the processing of your disability insurance claim. If your Long Term Disability claim is governed by ERISA, you have the right to receive a copy of your entire claim file, free of charge. So, the first thing we do is demand a copy of your file by writing to the insurance company. As part of the request, we cite the ERISA regulations that require the insurer to produce all the documents to which you are entitled, including, not only medical records but also internal communications including the insurance companies own notes regarding your claim. Upon receipt of our demand, the insurer has 30-days to provide us with your documents.
Once received, we review your claim file (which could range anywhere from hundreds to thousands of pages) in detail. We note any obvious misconceptions or documents that may be missing. We review the insurance company’s notes to see if it made any internal admissions that may help with your appeal. And we find and review the reports and/or notes from the insurance company’s doctor. Reviewing these reports will help us to better understand the reasons your claim disability insurance claim was denied.
2. We Outline the Reasons Your Claim Was Denied. After reviewing your long-term disability claim file, we re-review the insurance company’s denial letter. This time, while doing so, we make note of the specific reasons your claim was denied and the documents in the claim file that undermine the insurer’s position. By understanding the basis behind the insurer’s denial, we will be able to come up with a list of documents and other information necessary to combat and refute the insurance company’s flawed reasoning.
3. We Gather Additional/Updated Medical and Vocational Evidence in Support of Your Appeal and Conduct Comprehensive Research. Once we understand the reasons that your disability claim was denied, we begin requesting and obtaining additional documentation to further support your claim. The additional evidence will not only bolster the disabling nature of your symptoms; it will also address your specific restrictions and limitation and the deficiencies alleged by the insurance company. For example:
– If the insurer denied your claim, in part, because medical records from your doctors were not received, we will endeavor to obtain and submit those missing records with your appeal.
– If you suffer from back impairments, for example, and your Long Term Disability benefits are denied because of an alleged lack of evidence to support your restrictions and limitations, we may recommend you attend a Functional Capacity Evaluation to objectively verify the true severity of your pain, and explain how your symptoms prevent you from returning to work.
– If you suffer from cognitive problems and the insurance company claims there is no support for your deficits in memory, concentration, executive functioning, etc., we may recommend neuropsychological testing. This evaluation will both objectively document your cognitive functioning and explain how your impairments may prevent you from performing the duties of your own occupation.
– We may obtain and submit affidavits or narrative letters from your doctor(s) to better explain and document your symptoms, diagnoses, treatment, and restrictions/limitations. These documents can also clear up any misconceptions in the medical records and/or your doctors’ opinions.
– We may obtain and submit affidavits from you, your family, and/or your co-workers. These affidavits may be your only chance to “speak out” regarding your medical conditions and symptoms, and the effect they have on your ability to work. And the affidavits from your family and co-workers should provide first-hand observations of your symptoms and how they prevent you from performing your daily activities and/or work duties and responsibilities.
In addition, we conduct comprehensive research regarding your medical condition(s). It is extremely important for the insurance company to understand the exact nature of your medical conditions and symptoms. And we do not leave that to chance. We routinely submit scientific journal and other articles to explain the significance of your medical conditions and how they limit your ability to work.
4. We Prepare an Extensive Appeal Letter. Your insurance company will require the submission of a written disability appeal of your denied claim. We do not simply file a short letter stating that you “appeal” the decision. Rather, we generally prepare lengthy, comprehensive briefs containing legal arguments, often attaching hundreds (if not thousands) of pages of exhibits, including the above-referenced research. The briefs will explain both why you are disabled, and why the insurer’s decision is wrong. We also make sure to submit all available additional evidence in support of your disability appeal because it is exceedingly difficult to convince a court to consider additional information if your appeal is denied.
Contact a New York Disability Lawyer to Help with Your Appeal
ERISA Long Term Disability appeals are difficult to navigate, especially when you are suffering from the effects of a disabling medical condition(s). We are here to help. Hiller, PC’s New York Long Term Disability lawyers have extensive experience dealing with insurance companies. We understand what is necessary to prepare and file an administrative appeal that will convince your insurance company to approve your benefits. Contact the attorneys at Hiller, PC today at (212) 319-4000 for more information and a consultation for your ERISA disability claim.