LTD ERISA disability insurance claim denial Essex Richards

What To Do If Your Disability Benefits Are Denied

You’ve worked hard all your life. Never in a million years did you think that you would be unable to continue working or support yourself. But you plan for the unexpected, so you obtained long-term disability (LTD) insurance, perhaps through your employer or maybe you sought out one on your own. Year after year, the premiums are paid and you feel reassured by the fact that you have long term income protection, should you ever need it.

Then the unthinkable happens. You suffer a debilitating injury or sickness that renders you incapable of working. Thankfully you have a LTD insurance policy.

But the LTD benefits that were supposed to provide a safety net to protect you in the event of this very situation are not there. They either stopped suddenly or never began – leaving you overwhelmed and wondering how you will pay your bills and take care of your family.

Unfortunately, this scenario happens to genuine, hard-working people all the time.

We hope you never face this difficulty, but if you do, we may be able to help. Here are the 10 steps we recommend you take if the unthinkable happens and your disability benefits are denied or terminated.

  1. Consider contacting an experienced disability attorney.

This may seem obvious coming from disability attorneys, but it is legitimately the first and most important piece of advice we can give you. Challenging a disability benefit determination, especially if your claim is governed by ERISA (which stands for the Employee Retirement Income Security Act of 1974), is a complex, confusing process that can be difficult to navigate alone. ERISA is a federal law that provides for very specific procedures and time limits for filing disability claims. A single missed deadline will jeopardize your claim and your right to disability benefits may be forever lost. Moreover, the evidence you submit during the claim review process may be the only evidence you will ever have to rely on later in court. You have the right to hire any attorney to assist you at any stage of the disability claims process, which your claim reviewer will probably not tell you. In fact, they may even tell you don’t need one. Contacting an experienced LTD attorney as soon as possible can significantly maximize your chance of success.

  1. Request your claim file and policy in writing.

As soon as you receive your denial letter, you should request a copy of your claim file and insurance policy from your LTD insurer in writing. If your claim is governed by ERISA, the insurer must provide you with these documents within 30 days of your written request or face possible statutory penalties for failing to do so. Without these documents it is very difficult to determine the basis for the insurer’s decision or to prepare an effective appeal.

  1. Calculate your appeal deadline.

You have a limited amount of time to appeal if your disability claim is denied or terminated. The deadline to file an appeal depends on the language in your policy and the law governing your claim. Typically, if your claim is governed by ERISA, you must file your appeal within 180 days of receipt of the denial letter. If you miss the deadline, you may forfeit your rights to the claim and will likely never be able to challenge the denial.

  1. Do your homework.

Review the insurance company’s letter to determine why your benefits are being denied or terminated. Insurers frequently give the following reasons for denying a claim: “There is no objective evidence to support total disability,” “You are not disabled from performing Any Occupation,” “Your medical records do not support your Disability,” among others. You need to understand the insurer’s basis for its denial in order to prepare an effective appeal.

  1. Determine what restrictions are in your policy.

Some conditions are typically not covered or have only limited coverage under many policies. For example, emotional and mental conditions, such as depression and anxiety, are frequently limited to a maximum of 24 months of LTD benefits. It is important to be aware of any such restrictions in your policy, as there may be arguments t to overcome these defenses, depending upon the facts of your case and the specific language of your policy.

  1. Collect medical records and other evidence.

Gather and review all of your relevant medical records and any other relevant supporting documentation. Your claim is closed once a decision is made on your final appeal. Any relevant information you leave out of your appeal may never be considered by a court, which will make it virtually impossible to prove you are entitled to your LTD benefits.

  1. Write your appeal letter.

In your appeal letter, show how the evidence demonstrates that you are “disabled,” as defined by your policy. To do this effectively, you should reference documentation that supports your disability claim, which can include medical records, vocational reports, legal case law, and other relevant supporting documentation.

  1. Submit your administrative appeal.

Timely submit your appeal letter and supporting evidence using a trackable delivery method. Be sure to follow any directions provided in the insurance company’s denial or termination letter. Follow up with the insurance company to ensure they received your entire appeal submission in a timely manner.

  1. Monitor the status of your claim.

If your claim is governed by ERISA, the insurance company is required to make a determination on your appeal within 45 days, unless special circumstances exist that require them to take up to an additional 45 days, after notifying you of the reason for the delay. It is important to continuously monitor your claim to make sure the insurance company does not violate these important timing regulations without your consent. New regulations recently put in place by the Department of Labor may give you additional rights to pursue relief if the insurer blows any of these deadlines.

  1. Act promptly if your appeal is denied.

Once your appeal is denied, you must determine what steps are next available to you. If the plan has a voluntary appeal available, you may consider whether that is appropriate in your case. If the appeals process is exhausted and your claim is governed by ERISA, however, your only option to continue pursuing your disability benefits may be to file suit in federal court. You may also have recourse through alternative dispute resolution provisions in the policy or through your state insurance commissioner. Most likely, however, your recourse will be through filing suit in federal court. There are strict time limits in which you must bring a civil action or you may forever forfeit your right to the claim and to challenge the denial.

In short, navigating the disability appeal process can be overwhelming, especially if you have a severe physical or mental illness or injury. Even if you can navigate the procedural hurdles to keep your claim alive, you may not know what to substantively submit to support your entitlement to those benefits. Do not hesitate to seek guidance from a legal professional. If you would like assistance with your ERISA or private disability claim, we’re here to help. Simply click here or call (704) 377-4300 to speak to a member of our ERISA and disability team.

Disclaimer: We are ERISA attorneys, but we are not your attorneys and this article does not create an attorney-client relationship. The information in this blog post is provided for general information purposes only, and may not reflect the current law in your jurisdiction. No information in this blog post should be construed or seen as legal advice, nor is it intended to be a substitute for legal counsel on any subject matter.