Disability claim appeals are full of complex ERISA rules and requirements that are used by insurance companies to deter insureds from successfully appealing their denials of benefits. Claimants who file their appeal alone don’t have a very high rate of success and even those who do succeed have to navigate a cumbersome and confusing process to get the benefits they deserve. This blog has mentioned appeals many times, but the purpose of today’s article is to focus specifically on the options available to claimants appealing the denials of their short or long-term disability benefits and the techniques we’ve seen help insureds successfully appeal for their disability benefits.
The first step after receiving the denial letter from your disability insurance company is to try to calm down. It’s an incredibly stressful and frustrating event and you’ll be angry and upset. But you must understand that a denial isn’t personal – it’s just a very rational (but cold and heartless) business decision.
You’ll need to find and review the rules for an appeal in your specific policy. Don’t rely on just the Summary Plan Description (or SPD) that’s often provided by personnel or human resources departments – get a copy of the policy. Sometimes, these rules are also provided in the denial letter depending on the insurance company and the state. These rules are very important because the appeal is subject to the Employee Retirement Income Security Act of 1974 (ERISA). I have written a longer blog on the topic here. Disability insurance claims that are subject to ERISA have special rules and deadlines for the inclusion of new evidence that require special attention and careful planning. On all disability claim appeals, the most important rule is to understand and pay attention to the deadlines, as ERISA rules and deadlines are the most common ways for claimants to inadvertently damage their appeal. For example, most (but not all) policies allow for up to 180 days for an appeal. And within that 180 days, you should allow 60 days to prepare and appeal the denial, and then the insurer has up to 120 days to conduct a review of the appeal. Even if the greatest appeal in the history of disability claims is filed after 180 days, it will not matter.
Next, you and your disability claims consultant (or ERISA attorney) should review the denial letter thoroughly and understand the exact reason(s) your claim was denied – and there may be multiple reasons. There are four common reasons an insurance company will use to deny a disability claim: the medical records don’t back up the disability, you aren’t considered disabled from your occupation, your symptoms don’t match up with your diagnosis, and the policy doesn’t cover your disability.
Finding out the reasons your claim was denied is just the beginning of the battle. The initial response to your claim denial should include a list of specific questions for the insurance company to answer.
If medical records are incomplete or missing, find out exactly what information the insurance company has and what they need. Don’t assume everything that you thought had been provided is in the claim file. Common errors are that some critical medical records are not in the claim file or were overlooked and not considered by the claims examiner. See which specific medical records are in your claim file, ask what records they are specifically missing, find out what labs, tests or other exams they may want, and see if your doctor’s statements were incomplete.
If the insurance company questions your inability to work, make sure you know the occupation used to evaluate your claim. Check the job description and duties they are using to make sure they accurately and completely describe your actual job duties and activities. (More on this topic here.)
Insurance companies often claim that your symptoms offer insufficient proof of a condition, common in subjective symptom claims. Ask exactly what they are looking for or would accept to make an affirmative decision. You may need to get second opinions or additional testing to prove your claim.
Finally, if the insurance company asserts that your disability is not covered by your policy, ask for the specific clauses that exclude you from receiving your benefits.
After you have a clear understanding of the reasons for your denial and all of the deadlines and rules associated with your claim, you can make a plan for preparing and filing an appeal. The first step is to gather supporting information to fight the insurance company’s reasons for the denial. If you need to obtain existing or additional medical records, make sure to know the specific records you’re looking for.
If your doctor wasn’t clear enough for the insurance company on their attending physician claim forms, you need to work with your treating physician(s) and provide them the information they need to help complete the forms so that they support your claim.
If your job description is misleading or incomplete, prepare and submit a new, more thorough and accurate document. One of our earlier blog posts on best claim presentation practices gives a great overview on what’s necessary to create an iron-clad job description.
For so-called self reported symptoms, you should consult with your physicians to see about tests that may give more objective “proof” of your symptoms and conditions. Also make sure that any objective symptoms already present are brought out as the focus of the claim instead of the subjective symptoms.
In cases where the insurance company asserts that your disability is either excluded or not covered by your policy, the specific clauses should be reviewed by an expert disability claim consultant or attorney who have applied the language and knows the nuances of individual policy clauses as well as claims decision-making processes.
With all of this information in hand, it’s time to begin drafting your appeal letter. This is not the occasion to be angry or emotional. Do not resort to personal attacks or threats to the insurer – stay focused to move the process forward and ensure your claim appeal will be approved. First things first, make sure that your letter clearly lists your name, your policy number, your claim number and is addressed to the appropriate claims examiner or appeals department. Start by writing a brief overview of your position, stating how evidence proves you are indeed disabled. Then, list all of the new supporting documentation along with a detailed explanation as to why each item applies to the appeal of your claim. Make sure to include all of the additional information and documents you’ve accumulated.
Here is the other most common mistake made by claimants in appealing their claim. This is your one last chance to include anything and everything you want to be considered in your disability claim. Once the appeal is filed, it’s extremely unlikely that any more or subsequent information or documents will be considered. Some claimants believe that they need to quickly file their appeal or that it doesn’t really matter what’s submitted. This is absolutely incorrect and is often a fatal error in a disability claim.
Send the appeal package by fax, overnight or certified mail and keep all receipts that can prove the letter was sent prior to any deadlines.
This begins the waiting period again. Similar to an initial claim for benefits, after a few weeks you should send a follow-up letter asking for the status of the appeal of the claim and to confirm that the appeal letter and supporting documents were received.
You may want to file a complaint with your state insurance commission as part of the process of appealing the denial of your disability benefits. Before litigating your disability claim, you can be required to go through the appeals process. Preparing and filing a lawsuit is outside the realm of our expertise or services and will require the help of an experienced and licensed disability claim attorney.
A disability claim appeal can be a very trying and exhausting process, but much of the grief and worry of these appeals can be avoided by following a few simple guidelines and having a plan for your appeal before you begin to prepare it. Hopefully, this article helps you appreciate the disability ERISA appeal process and gives you a better understanding of the process you hopefully will never have to undertake. For more help on your specific disability appeal or for questions on any other aspects of the disability claims process, please do not hesitate to contact our offices toll-free at (855) 828-4100 or sign up for a free consultation on our website.