Effective Long-Term Group Disability Appeals

Workers who have applied for group long-term disability benefits under an employer-sponsored insurance plan do not have to take no for an answer. They have important legal rights including filing a timely, comprehensive administrative appeal with their insurer after a bad-faith claim denial, and after that, a federal ERISA lawsuit to collect their disability benefits.

In this blog post, we explore how workers can make the most of an administrative appeal and help ensure they receive the long-term group disability benefits they deserve.

Overview of Long-Term Disability Benefits and Administrative Appeals

Many employers pay for long-term disability (LTD) insurance for their employees as part of an employee benefits package. Group LTD coverage protects workers against a long-term loss of income when an employee cannot perform the important duties of their occupation because of a disabling sickness or accident. Unlike workers’ compensation insurance, it covers employees against the financial toll of both non-work-related disability and a disability arising out of work, LTD covers you if you become disabled from a sickness or accident that prevents you from performing the important duties of your occupation.

A complicated federal law called the Employee Retirement Income Security Act, better known as ERISA, governs the management and implementation of employer-provided and other group LTD insurance (as well as some other employee benefits). Among other rules, ERISA requires that employer-provided LTD insurance policies give employees the legal right to file an administrative appeal with the insurance company after the denial of a valid claim. Below, we discuss effective ways to enforce those legal rights.

ERISA generally applies to LTD policies provided by employers, unions, and professional organizations. Some people may choose to purchase their own LTD coverage through an insurance broker or agent. ERISA generally does not govern these individual policies, and the rules for filing an administrative or judicial appeal after a wrongful claim denial under individually bought policies can vary widely. Speak with an experienced long-term disability lawyer if you have a disputed claim under an individual disability policy you purchased directly from an agent or broker

Getting the Timing Right

A group LTD insurance policy administrator has a legal obligation to provide a detailed explanation of why a group disability claim was denied. The denial must identify any policy provisions that justify the denial; must give you notice of your legal right to get a copy of the insurer’s claim file, and must describe your legal right to an administrative appeal.

Under ERISA, you generally have a minimum of 180 days from the date of an LTD claim denial to submit an administrative appeal but check your policy certificate to be sure. Be aware that you may need all of that time to prepare an effective administrative appeal. You are better off hiring a top-rated long-term disability insurance lawyer than doing this yourself as the appeal must lay out the legal theories supporting the claim, all medical, vocational, occupational, financial evidence supporting the claims and a complete rebuttal to the insurance companies reasons for denial.

The insurer must generally review and respond to your administrative appeal within 45 days.

You must take care not to miss strict and unforgiving administrative appeal submission deadlines. With few exceptions, missing them means losing your legal rights.

Effective Administrative Appeal Submissions

Here is something group LTD policy issuers and plan administrators do not want you to realize: Getting your administrative appeal right is critically important. Insurers would like you to think that it does not take much effort to submit a proper administrative appeal. They may even describe the types of information an administrative appeal should contain in the Summary Plan Description you received from your employer.

Do not get fooled. The content and detail of your administrative appeal make all the difference in the world in whether your administrative appeal succeeds or fails.

At a bare minimum, an effective timely, comprehensive administrative appeal:

• Includes copies of all claim-related correspondence you have exchanged with the LTD insurer;
• Addresses, point-by-point, every single reason the LTD insurer gave for denying your claim;
• Supply supporting documentation for each of your arguments, including all relevant employment records, medical, occupational, vocational, and financial evidence supporting the claim.
• Provides statements and chart records from qualified, treating medical professionals to address any dispute about the nature, extent and severity of your disability;
• Cites applicable laws, regulations, and policy provisions, where necessary; and
• Highlights any objections you have to the handling, procedural irregularities or the substance of the claim file provided to you by the insurer (which you must have requested).

Of course, the specific contents of an administrative appeal can vary at the margins. However, the bottom line remains the same: An effective administrative appeal to an LTD carrier attacks every reason given for the denial, and supports every argument you make, in meticulous detail and with as much supporting evidence as possible. Under the provisions of many LTD plans, your administrative appeal may represent your only chance to frame the issues for your appeal, and to supply important evidence to buttress your arguments.

Should your insurer deny your claim, you may file a federal ERISA lawsuit, but if your administrative appeal and underlying claim application didn’t include everything the judge will need to rule in your favor, you can’t go back and add to the record in federal court. The judge may only review the underlying record in the administrative appeal and underlying claim application, and will generally only overturn the insurer’s decision if it was arbitrary and capricious.

That’s why you need to hire an experienced group long-term disability lawyer rather than trying to file a claim or administrative appeal yourself.

Effective Use of a Top-Rated Long-Term Group Disability Attorney

We understand the reluctance some people feel about hiring an attorney. If you have read your Summary Plan Description’s chapter on your administrative appeal rights, you may even think that you can tackle the administrative appeal on your own and still reverse a bad-faith claim denial.

That would be a big mistake.

The fact is, most people do not have the know-how to prepare an effective administrative appeal that pays strict attention to detail, reflects skilled deployment of legal arguments, and contains significant supporting evidence.

You need an experienced long-term group disability attorney to help prepare that submission, both to make sure the submission contains all the necessary information, and to ensure it avoids legal pitfalls that could doom an administrative appeal even before it gets underway.

We encourage anyone who receives a bad-faith claim denial from an LTD carrier to contact an experienced long-term group disability lawyer immediately.

Remember, the clock for filing an administrative appeal begins ticking on the date of the wrongful claim denial, and you do not have a moment to lose. Collecting, organizing, and presenting the evidence and arguments needed for an effective group LTD administrative appeal takes time, particularly if you need to consult with and obtain testing and medical expert reports.

The sooner you speak with an experienced California disability attorney, the better your odds of submitting the strongest group LTD administrative appeal possible. If you are in the process of or anticipating a group long-term disability claim application or administrative appeal, contact an experienced long-term group disability attorney today to learn about your legal rights.