Long Term Disability Claim and Appeal Process
If your Long-Term Disability is Denied you can file an Appeal
Author: Attorney Lonnie Roach
If your long term disability claim is denied, or if you have received a letter terminating your existing disability benefits, in many cases you can file a successful appeal. Not only does the appeal give you a chance to overturn the decision, but it is also a required step in order to preserve your right to file a lawsuit at a later date.
Filing a long-term disability claim can be a confusing process.
Whether you have purchased an individual LTD policy with a private insurance company or have a group policy through your employer will determine the procedures and steps you need to follow to have a successful claim. An LTD policy purchased by an individual is a contract between an insurance carrier and the policy holder and governed by state law. If you have an LTD plan through your employer, your policy is governed by ERISA.
ERISA is a federal law which sets minimum standards for retirement and health plans instituted by private employed to protect participants in those plans.
ERISA requires those plans to provide information about plan features and funding to its participants and requires plan trustees and administrators to operate the plans solely in the interest of plan participants and beneficiaries. ERISA regulations govern requirements for processing benefit claims, timelines for decisions and the rights of policy holders if a claim is denied.
If you are injured or ill and considering filing an ERISA-governed long-term disability claim, the first thing you should do is obtain a copy of your policy and summary plan description from your human resources department or the insurance carrier.
Pay close attention to the policy’s definition of “disability,” timelines, exclusions, and waiting periods.
- Definition of disability. In most LTD policies, “disability” is defined as “an inability to perform, due to illness or injury, material duties of your own occupation.” This means you are only required to prove that you can’t do your job. Some policies may define “disability” as the inability to perform any job, which makes proving disability more difficult.
- Time limits. All LTD policies have strict deadlines for applying for benefits and subsequent appeals. Missing a deadline is a sure way for an insurance company to deny a claim.
- Exclusions and limitations. LTD policies generally do not cover pre-existing conditions. Certain conditions like drug abuse, alcoholism, and attempted suicide are not covered at all.
- Waiting period. This is usually a period of 3 to 6 months between the time you are disabled and when you can begin receiving payments.
- File a claim with your company-provided long term disability insurance.
Your plan booklet should include information on where to file a claim, what information and documents to submit, and who to contact if you have questions about your plan.
You will need to complete a series of forms and provide documentation. Your medical records and doctors’ opinions are the most important elements of your case. An insurance company will obtain your recent medical records, but do not assume those records will be complete or accurate. Get a copy of your claim file and check to see if any records or information are missing, and if so, provide it.
If you have been denied disability don’t give up! Contact a Disability lawyer at 512-454-4000 for a free consultation and get the benefits you deserve.
The insurance company will investigate your claim, reviewing claim forms, medical records, pharmacy records, financial records and doctors’ statements.
The insurance company may also ask that you attend an examination by one of their physicians. ERISA sets specific time limits for LTD plans to make a decision on a ERISA claims. Time limits are counted in calendar days, so weekends and holidays are included. Generally, a plan is required to make a decision within 45 days of receiving a claim. If a plan needs additional time to review a case, they must contact you in writing, explaining why. If the plan needs more information from you, they must allow you at least 45 days to respond. Insurance companies are allowed 30-day extensions and it can take up to 105 days before a plan reaches a decision.
If your ERISA claim is denied, the plan administrator must notify you in writing or electronically with the following information:
- A detailed explanation of why the claim was denied, stating why the plan disagreed with the disability or vocational expert.
- The notice must refer to the specific plan provisions on which the denial was based.
- A statement that you are entitled to receive copies of all documents relevant to your claim at no cost.
- Plan rules, procedures or criteria that were relied upon in denying your claim.
- A description of the plan’s appeal process, including deadlines, and a statement of your right to pursue a claim in court if your claim is denied on appeal.
If your claim is denied, you must file an Administrative Appeal. You should strongly consider contacting an experienced ERISA attorney to assist you in the appeal process.
You will have 180 days to file a claim appeal in writing.
An appeal not only gives you the chance to overturn the decision; it is a required step in order to preserve your right to file a lawsuit at a later date. The importance of this deadline cannot be overemphasized. If you miss this filing deadline, you will permanently lose the right to appeal.
An appeal must include all the evidence you would want a court to consider.
This is known as the administrative record and includes every form, medical record, letter, and any other type of documents provided by the claimant or the plan administrator, from the filing of the original claim for disability benefits to the final denial of the appeal. When the appeal process is complete, you will not be able to add any more evidence. The appeal process is your final opportunity to add pertinent information to the claim record. If your appeal is denied and you decide to file a lawsuit, the administrative record will be the only evidence a judge will consider.
Your attorney can provide much needed guidance to you as to additional medical information that might strengthen the appeal, and future suit, should a lawsuit become necessary.
You do not want to risk entering a lawsuit with an incomplete or weak claim record, which would severely decrease your chances of being awarded the disability compensation you deserve.
When a claim is appealed, it must be reviewed by a new person and not the evaluator (or the evaluator’s subordinate) who reviewed the initial claim.
The new evaluator will review all the records and information submitted and consult with medical professionals. The insurer will have 45 days to make a determination and will be allowed one automatic 45-day extension, extending the time to 90 days to decide an appeal. If an insurer requests more information from you, they are permitted to suspend deadlines until you respond.
If the insurer denies your appeal, you have the option to file a lawsuit.
Claimants can only pursue a lawsuit if they have gone through the entire appeals process. Claimants in ERISA disability cases are not allowed to seek damages for bad faith or pain and suffering, only disability benefits, attorney fees, and costs. A federal court will review only the evidence and information that was submitted by you and your attorney when the initial claim was filed and during the appeal and decide whether the plan’s decision was arbitrary and capricious. There will be no testimony by you, your doctor, or anyone else – another reason to make sure your claim file is complete and accurate. A Federal Judge will typically determine whether the ERISA plan’s decision was arbitrary and capricious. When the judge rules, the losing party may, in select circumstances, appeal.
Once the court rules, the losing party can elect to appeal in select circumstances.
It’s easy to see how complicated ERISA claims are and how a claimant who is unrepresented by an attorney can make serious mistakes and lose their claim.
A claimant can fill out a form incorrectly, miss a deadline, or fail to submit important documentation. An experienced LTD attorney who has thorough knowledge of ERISA rules and regulations will avoid these missteps and act on your behalf, increasing your chances for success. If a claim has been denied, it’s absolutely necessary to have legal representation to avoid missing critical deadlines or making other serious mistakes during the appeals process. If you decide to file a lawsuit, an LTD attorney can prepare your case against an insurer, working with your medical providers and ensuring your file contains all the evidence relevant to your case. In order to protect your interests, you should contact an attorney as soon as you are unable to work.
Disability benefits are an important source of income for those who are unable to work. If you are not able to work due to accident or illness, you may be eligible for Social Security Disability or Long Term Disability benefits. If you have applied for benefits and been denied, contact the attorneys at Bemis, Roach and Reed for a free consultation. Call 512-454-4000 and get help NOW.
The LTD Appeal Process
Bemis, Roach & Reed has successfully handled cases against the following insurance companies:
For answers to other questions regarding ERISA please see our page ERISA Frequently Asked Questions or call toll free (866) 433-4979 for a free personal consultation.
Bemis, Roach & Reed has successfully represented long term disability clients throughout the state of Texas and can easily fight for claims across the state by working the cases remotely, via phone, fax and e-mail.
Author: Attorney Lonnie Roach has been practicing law for over 29 years. He is Superlawyers rated by Thomson Reuters and is Top AV Preeminent® and Client Champion rated by Martindale Hubbell. Through his extensive litigation Mr. Roach obtained board certifications from the Texas Board of Legal Specialization. Lonnie is admitted to practice in the United States District Court - all Texas Districts and the U.S. Court of Appeals, Fifth Circuit. Highly experienced in Long Term Disability denials and appeals governed by the “ERISA” Mr. Roach is a member of the Texas Trial Lawyers Association, Austin Bar Association, and is a past the director of the Capital Area Trial Lawyers Association (Director 1999-2005) Mr. Roach and all the members of Bemis, Roach & Reed have been active participants in the Travis County Lawyer referral service.
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