Long Term Disability Claim and Appeal Process
Filing and Appealing a Long-term Disability Insurance Claim
Author: Attorney Lonnie Roach
If you become disabled and unable to work for an extended period of time, it’s important to review your insurance options. Long-term disability insurance may be provided by an employer or through a privately purchased insurance plan. An LTD policy purchased by an individual is a contract between an insurance carrier and the policyholder and governed by state law. If you have an LTD plan through your employer, your policy is likely governed by ERISA. ERISA (Employee Retirement Income Security Act of 1974) is a federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for participants in these plans. Whether you have an individual LTD policy or a group policy through your employer will determine what procedures and steps you need to follow for a successful claim.
If you are suffering from the effects of a disabling ailment that keeps you from working you may qualify for disability benefits.
- Review Your LTD policy
You should obtain a copy of your LTD policy and plan summary from your employer’s HR department or insurer as soon as you become injured or ill and thinking of filing a claim.
Sometimes this is easier said than done. If your HR department or insurer fails to provide a copy, request a copy of your policy in writing from the plan administrator at the insurance company. All requests should be sent by certified mail, return receipt requested.
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.
Your plan booklet should include basic information on where to file a claim, what documents to submit, and who to contact if you have questions about your plan.
Pay strict attention to the following terms of your policy:
- Definition of disability.
- Time limits.
- Waiting period.
- Exclusions and limitations.
Most LTD policies define “disability” as “an inability to perform, due to illness or injury, material duties of your own occupation.” This means you only need to prove that you are unable to perform your own job. Other policies define “disability” as the inability to perform any job, which makes proving you are disabled more difficult.
LTD policies have strict deadlines for filing for benefits and appealing denied claims. Missing a deadline is a sure way for an insurance company to deny a claim.
This is a period of 3 to 6 months between the time you become disabled and when you can begin receiving payments.
Usually, LTD policies will not cover a pre-existing illness or injury; other conditions like alcohol and drug abuse, alcoholism, a crime-related injury or self-inflicted injury are not covered at all.
- File a claim with your company-provided long term disability insurance.
You can file a claim online with your disability insurance company.
You may also be able to file a disability claim by phone, fax, or mail. Some insurance companies may have their own preferred method, but the details should be available in your policy. You will need to complete some required forms, often called a claim packet, and provide documentation as part of the initial filing process. The forms in a claim packet detail your condition to prove that you’re disabled and include the following:
- Employee’s Statement.
- Employer’s Statement.
- Doctor’s statement.
- Direct deposit information.
This statement includes basic information such as name, address, birthdate, places of work, the extent of your disability, and other sources of income you may have, including pension benefits, veterans benefits, and other disability benefits you already receive. The form may also ask you the names of your medical providers and details about your medical insurance.
Your employer will have to provide information describing your role within the company, your income and how your disability affects your ability to perform your job. Your employer will also have to state the last date of your employment if you had to leave your job because of your disability and whether you’ve filed for workers’ compensation. If you have a group disability insurance policy, your employer will include how much of the insurance premiums they cover and how much paid by you.
The attending physician’s statement (APS) must be completed by the physician treating you and include a diagnosis, your medical history, and any treatment you’ve been receiving. This form also documents the severity of your impairment, as well as whether the physician believes you’ll be able to return to work and when.
The insurance company may also include a form to enroll in direct deposit to receive your benefits.
You should also submit any other documentation that supports your claim such as medical records, test results and doctors’ notes.
It takes anywhere from a few weeks to a little over a month to process a disability claim. Providing as much information as you can when you first file your claim may help avoid delays.
The insurance company will review your claim forms, medical records, pharmacy records, financial records and doctors’ statements and may also ask you to attend an examination by one of their physicians.
ERISA sets specific time limits for LTD plans to make a decision on a claim. A plan is required to make a decision within 45 days of receiving a claim, but if additional time is needed to review a case, a plan must contact you in writing, explaining why. If the plan requires more information from you, they must at least 45 days for you 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 Claim is Denied – Appealing an Adverse Decision
If your ERISA claim is denied – and many LTD claims are denied initially – don’t get discouraged; you can appeal the decision.
The plan administrator must notify you in writing or electronically with a detailed explanation of why your claim was denied and referring to specific policy provisions on which the denial was based. This includes plan rules, procedures or criteria that were relied on in denying your claim. You should also receive a description of the plan’s appeal process, including deadlines and a statement of your right to file suit if your claim is denied on appeal.
You must file an appeal within 180 days.
An appeal gives you the opportunity to overturn the insurer’s decision and 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 and your claim is governed by ERISA, you will lose the right to appeal – permanently.
An appeal must include all the evidence you want a court to consider, including every form, medical record, letter, and any other type of documents provided by you or the plan administrator, from the filing of the original claim for disability benefits to the final denial of the appeal.
This is known as the administrative record and when the appeal process is complete, you will not be able to add any more evidence. If your appeal is denied and you decide to file a lawsuit, the administrative record will be the only evidence a judge will consider.
A claim must be reviewed by a new person and not the evaluator (or the evaluator’s subordinate) who reviewed the initial claim when it is appealed.
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 decision and is allowed one automatic 45-day extension; this would extend the time to decide an appeal to 90 days. If an insurer requests more information from you, they are permitted to suspend deadlines until you respond.
- File a Lawsuit in Federal Court
If your appeal is denied, you have the option to file a lawsuit.
When an ERISA claim is denied by the LTD insurer or plan administrator, the claimant must exhaust the plan’s appeals process before filing a lawsuit. This means you must ask your insurance company to review its decision (called an administrative appeal) before you can sue. However, if you hold an individual LTD policy, you are not required to exhaust your administrative appeals before filing a lawsuit and may also present new evidence in court during the lawsuit. This does not mean that an individual LTD policyholder should not go through the entire appeals process first – it is always better to prevail early in the claims process.
If you have a group policy, under ERISA, you case will likely be heard in in federal court where your case will be decided by a judge.
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. The 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 correct. The administrative record is a major key to supporting your claim and winning a lawsuit. This cannot be overemphasized. There will be no testimony by you, your doctor, or anyone else, so make sure your claim file is complete and accurate. In contrast, individual policyholders may sue in state court for breach of contract, negligence, bad faith, or other causes of action and are entitled to a jury trial.
The standard of review used by courts also differs between group or individual plans.
In cases governed by ERISA, the actions of insurers and plan administrators are often evaluated under an “abuse of discretion” standard, meaning that, unless the insurance company’s decision to deny benefits is completely unsupported by the evidence, or clearly incorrect, the federal judge cannot overturn the decision. Under state laws that apply to individual policies, insurance carriers are not given the same benefit of the doubt. Instead, the state judge or jury will look to whether the insurance company fulfilled its promises to you under your LTD contract.
- Obtain Legal Representation
ERISA claims are extremely complicated and it’s easy to see how a claimant who is not represented 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 with 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 retain 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. To protect your interests, contact an attorney as soon as you are unable to work.
Bemis, Roach & Reed has successfully handled cases against most disability insurers.
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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