How to Appeal a Long-Term Disability Denial

The last thing you need when you have suffered a disabling accident or health setback is to have your long-term disability insurance provider deny a claim. Unfortunately, as America’s working population of Baby Boomers and post-Boomers ages, we expect more and more long-term disability carriers to push back harder and harder against benefits claims by newly disabled Americans. Here are some tips on how to fight back properly and timely appealing that bad-faith claim denial.

Long-Term Disability Benefits: A Quick Overview

Many American workers are covered against the costs of a long-term disability under an employer-provided, long-term disability insurance plan, or through a union or trade organization. Generally speaking, these plans pay benefits to workers with long-term disabilities that prevent them from reliably performing the important duties of their occupations, and replace a percentage of their employment income or earnings.

Americans can also purchase long-term disability insurance directly from an agent or broker. AFLAC (of the talking duck commercials) is the country’s largest provider of this sort of private long-term disability insurance.

The major distinction between group and employer-provided long-term disability insurance and a policy you purchase on your own is that employer-provided plans are generally subject to the requirements of a federal law called the Employee Retirement Income Security Act, better known as ERISA, unless you work for a government, school, church, or a sole proprietor. ERISA does not generally govern most individual long-term disability insurance plans.

Among other provisions, ERISA dictates the basic procedures that employees have to appeal wrongful denials of claims for long-term disability benefits. When ERISA does not apply to an insurance benefit plan, the plan’s contractual terms (subject to state insurance laws) lay out the insured person’s legal rights.

The remainder of this blog discusses appeals under ERISA-governed plans, as they constitute the bulk of group long-term disability plans in effect nationwide.

Timelines Applicable to Your ERISA Administrative Appeal

ERISA guarantees your legal right to appeal a wrongful denial of a long-term disability claim decision. In the typical scenario, you file a claim for long-term disability benefits through your employer-provided plan. Normally, the plan has 45 calendar days from the date of the claim submission to respond.

In the case of a wrongful claim denial, the response you receive from the plan administrator must give a detailed explanation for the reasons the claim was denied (including references to any applicable provisions in the long-term group disability benefits plan), notice of your legal right to obtain a copy of the claim file or administrative record and a description of your appeal rights.

By law, you generally have 180 days to file an administrative appeal of the wrongful denial of long-term group disability benefits with your group long-term disability insurance company. The plan administrator typically has no more than 45 days from the date of the appeal submission to review it and respond with a decision unless they request a legitimate extension reason.

What Your Initial Appeal Should Contain

Your plan’s Summary Plan Description may provide a generalized overview of what information to include in an administrative appeal of a wrongful long-term disability claim denial. In our experience, however, the Summary Plan Description rarely highlights as much as it should or what you really need in your appeal.

Your administrative appeal must address, in as much detail and with as much supporting medical, occupation, financial, and vocational evidence and documentation as possible, every reason the plan administrator has given for denying your long-term group disability benefits claim. Your legal rights to pursue further appeals, and to later file a federal ERISA lawsuit, depends on the quality and thoroughness of your administrative appeal.

Before submitting an initial appeal of a wrongful long-term group disability benefits claim denial, you should gather all of the compelling subjective and objective medical evidence and proof you can. This includes your claim file (which you have the legal right to obtain from the plan administrator under ERISA), witness affidavits, accident reports, your treating physician’s chart notes and complete medical records and testing, pharmacy records, and your treating doctor’s detailed opinion on why you are unable to perform the important duties of your occupation, or in some cases, any occupation by which you are trained, educated, or suited, taking into consideration your station in life.

Take, for example, a common reason a plan administrator might give for denying a claim: that you do not qualify as disabled under the terms of the plan because your medical condition does not prevent you from performing the important duties of your occupation.

In appealing that decision to the plan administrator, a complete claim appeal submission would likely need to include:

• A sworn personal statement from you countering any reasons given for the wrongful claim denial about which you have personal knowledge;
• All relevant correspondence relating to the initial claim and its wrongful denial;
• All relevant medical records from before and after the time you submitted the claim;
• All relevant employment records kept by your employer about your condition, your occupational duties, and your history of disability;
• Reports and evaluations from doctors and other healthcare experts to respond to reasons given for the wrongful denial of your claim;
• Statements from witnesses who can speak about issues relevant to your disability from personal knowledge, if applicable;
• Photographic and video evidence to counter reasons given for your wrongful claim denial; and
• Vocational support outlining the physical and mental demands of your occupation and why, based on objective and subjective medical support, you are unable to work.

This is just a sample list, of course. Every appeal is different. The point is, your initial appeal of a wrongful denial of long-term group disability benefits should contain compelling medical evidence and proof to dispute every reason given for the wrongful claim denial.

Your administrative appeal offers your only chance to submit relevant evidence in your favor. Should your group long-term disability insurance company deny your claim and uphold their claim denial on appeal, in a federal ERISA lawsuit, you cannot submit any new evidence, conduct discovery to get insurance company documents, call witnesses on your behalf, cross-examine the insurance company’s witnesses, or try your case before a jury. The Federal Court Judge will review the medical records, statements, and documentation you and your carrier used in the underlying claim and your group administrative appeal and will generally only overturn the insurer’s decision if it was arbitrary and capricious.

How a Long-Term Group Disability Attorney Can Help

If our description of what an administrative appeal should contain sounds like a big undertaking, that’s because it is. An experienced long-term group disability insurance attorney can help.

Too many disabled workers make the critical mistake of waiting until after filing a claim, seeing it get denied, and filing an incomplete administrative appeal, to speak with a long-term disability insurance attorney about their legal rights under ERISA and the terms of their long-term group disability benefits plan. Ideally, you should retain an experienced long-term disability insurance attorney to help you file your initial long-term group disability benefits claim.

Unfortunately, most people do not think with a legitimate sickness or injury their claim will be denied. In most cases, the next-best decision you can make is to speak with an experienced long-term disability ERISA attorney as soon as you receive a wrongful denial of your long-term group disability benefits claim. From the date of denial, the 180-day clock is ticking on you exercising your legal rights in a thorough and timely manner.

Most lawyers, let alone workers, do not have the understanding of ERISA or how to file a successful administrative appeal of a wrongful long-term disability insurance claim denial. They do not know what information to seek in advance, much less what information to include in an appeal submission. Nor do they appreciate how their administrative appeal will affect their legal rights down the road.

Bottom line: Leave the intensive preparation of your long-term disability appeal to an experienced, skilled ERISA attorney.