The Process for Long Term Disability Appeals

The Process for Long Term Disability Appeals

If your employer offers group long-term disability insurance, then you probably made a claim with the insurance company after falling ill or being injured.

Once denied, you should begin considering whether to bring an appeal.

To succeed on your denial of benefits claim, you’ll need to prove the following:

  • You properly made your requests for benefits.
  • You went through the plan’s administrative appeals process.
  • You are entitled to long-term disability benefits under the terms of the plan
  • You were denied your long-term disability benefits.

Below, we explain the process for long term disability appeals. If you have questions about this process or would like our assistance, schedule a free consultation with our ERISA lawyers.

Understanding Disability Denial Appeals

Read Your Denial Letter

The first step of this process should be to read your denial letter. When you are denied for long term disability, your insurance company usually sends you a letter explaining why you were denied and how you can make an appeal. Always follow the information that your insurance company gives you; the process might vary between companies.

Identify the Reason for Denial

Next, identify why the insurance company denied your claim, which can be found in your denial letter. The reason why you were denied will determine how you appeal to the denial. For example, if you were denied because you did not have enough medical evidence of your disability, your appeal will include your medical records.

Get a Copy of Your Insurance Company’s Long Term Disability Policy

Different insurance companies include different plans and terms for long term disability. To find out exactly what you are entitled to, get a copy of your company’s long term disability policy. The appeals process can be confusing, so we advise you to get a lawyer to help you.

Gather Evidence to Support Your Appeal

To succeed on your denial of benefits claim, you’ll need to prove the following:

  • You properly made your request for benefits.
  • You went through the plan’s administrative appeals process.
  • You are entitled to long-term disability benefits under the terms of the plan.
  • You were denied your long-term disability benefits.

Document Your Injury

Often, our clients need additional medical information to qualify for long-term benefits. To help build up the medical record, we often need to work closely with doctors and other medical professionals to better understand your illness or injury.

Your condition might also have worsened since you initially applied for benefits, and we will carefully document your currently existing state.

There is a critical reason why you need to fully document your illness or injury at the appeal stage. If you decide to later bring a lawsuit against the plan or its administrator, then you will not be able to supplement the record. Instead, a court will only review the evidence that was before the plan for the administrative appeal.

Administrative Appeals Process

Once you have received your denial, you will need to prepare for the administrative appeals process. These are the internal appeals that the plan should offer, as opposed to filing a lawsuit in court.

Sometimes, the plan will realize that they made a mistake when denying you a benefit, so they have a chance to correct the mistake. This is how an internal appeal should work—at least in theory.

At the appeal stage, most of the work will involve proving that you are entitled to long-term disability benefits under the terms of the plan. This requires an experienced ERISA attorney who can review the detailed requirements in your plan and check whether you have sufficient evidence that shows you qualify.

Request the Administrative Record

You should begin by requesting the administrative record in your case. This record can contain important information about what really motivated the insurer to deny your claim. You have a right to the administrative record, and instructions for how to get it should be provided in your Notice of Denial.

Why Documentation is Important to Your Claim

Evidence, medical records, and documentation is extremely important in long term disability appeals. If you lack any of these elements, you might not get the benefits that you deserve.

Consider the following: Kathy decides to file a long-term disability claim because she has suffered nerve damage in her arm. The initial claim was denied, and Kathy decided not to submit additional tests or medical evidence during her appeal. Once she exhausts all administrative appeals, she decides she wants to sue in federal court, and she wants to introduce new medical evidence of the full extent of her injury.

Unfortunately, since Kathy did not file this supporting documentation during her administrative appeal, she can’t introduce it in her court case.

Contact an ERISA Attorney

To make sure you have the best chance of success, you should meet with an ERISA attorney who will track down all helpful pieces of supporting evidence and have it entered into the record so that a court could later consider it.

Contact us today for a free consultation.