Have you received a long-term disability (LTD) denial from your insurer when you never even saw the doctor who made the decision? These “third-party medical reviews” or “peer reviews” are routinely used by insurance companies to deny LTD claims.
If your claim was denied after a medical review, contact our experienced long-term disability attorney for the help you need. We will review your denial letter for free and provide strategies on the best way to reinstate your benefits. Call us today at 816-203-0143 for your free denial letter review.
Peer Reviews to Deny Long-Term Disability Benefits
The first step after an LTD denial is to review your denial letter carefully to understand why your claim was denied in the first place.
- Was it due to insufficient medical evidence?
- Did the insurance company believe you didn't meet the definition of disability?
- Were there any red flags in your medical records that triggered the denial?
When applying for LTD benefits, your insurer may rely on medical records and opinions from qualified medical professionals you interacted with to determine whether you qualify for coverage. This could include information from your doctor as well as reports from other attending physicians, such as your treating medical specialists.
One of the most common reasons LTD benefits are denied is due to the insurance company relying on the opinion of a medical reviewer you probably never met. When reviewing your claim, insurers often hire a doctor or other medical professional to conduct a “Peer Review” of your records. These "doctor for hire" assessments are based only on written records— no in-person examination is required. These paper reviews lack the nuance and context that an in-person assessment can provide and are prone to bias or “cherry-picking” of details to deny your claim.
The insurance company’s hired doctor may also have an incomplete or outdated understanding of your medical condition, or they may lack the training or medical specialization to properly evaluate your condition. And don’t forget – these doctors are being paid by the insurance company to review your file and many others, which can also lead to bias.
If your medical review comes back with a denial of your LTD claim, remember you have the right to appeal and try to reverse the denial.
Appealing a Denial After a Paper File Medical Review
If the insurer has denied your claim, you should check your policy to confirm your right to appeal the decision. Most LTD policies governed by ERISA will give you the opportunity to appeal, which allows you one opportunity to present evidence in support of your claim and argue that the denial was based on flaws in the insurer’s process.
Here are steps on how to prepare for your appeal:
Request and Review Your Claim File and LTD Policy
After a denial, you should request your complete LTD claim file. This should also contain the LTD policy and plan documents. Along with our attorney reviewing your file, you will also want to read through all those documents carefully to identify any mistakes or oversights made by the insurance company. This includes understanding the policy, its coverages and exclusions, and what types of medical evidence is needed for your appeal. Our attorney will guide you through this process.
Be aware of time limits specified in your policy about submitting paperwork and appealing decisions. These time limits are usually very short and the failure to act promptly can bar your right to recover benefits or win your appeal.
Gather All Necessary Documents
One of the common reasons for a medical reviewer to deny your claim is insufficient medical evidence. Our attorney will assist you in gathering the required documents, and obtaining any updated records from your providers and/or talk to them about whether they will support your disability claim in writing. Make sure to collect any documentation related to your disability, including exams, imaging, test results and doctor notes and statements.
Additionally, if you have any letters of recommendation or supportive statements from family members, you will want to include these in your paperwork as well. Including all this documentation in your appeal helps to solidify your claim.
To make your response as comprehensive as possible, our attorney will carefully go through the reasons used for the LTD denial and address each point in your appeal by highlighting any discrepancies or mistakes. Gathering and submitting all the necessary documents and testimonies can make or break your appeal—so our attorney will ensure it's done correctly and on time! Remember, if you appeal is not successful, ERISA provides that the next remedy is to file a lawsuit. ERISA generally bars the introduction of new information in the lawsuit stage of a case, so we will need to make sure to include all required information when filing your appeal.
Hire Our Experienced Long-Term Disability Attorney
Long-term disability claim appeals are complex and time-consuming. Most employer-sponsored LTD policies are governed under the federal law ERISA, which provides certain safeguards to insurance companies and makes it harder for claimants to win.
Overturning a disability claim denial under ERISA often requires proving the insurance company's decision was "arbitrary and capricious." This is different than a typical breach of contract case.
While you may try to handle certain legal issues on your own, an ERISA LTD denial should not be one of them. Consult with our experienced disability attorney early on to guide you through the process and protect your rights. Having our LTD attorney by your side throughout this process can help ensure your appeal is as strong as possible, and you receive the benefits you deserve.
Our LTD Attorney Will Appeal Your Long-Term Disability Denial
Many long-term disability claims are wrongfully denied, but the good news is that you don't have to accept your denial. If you or someone you know was denied long-term disability benefits due to a medical review by a doctor you never saw, our long-term disability attorney will review your denial letter for free and prepare an appeal on your behalf.
Contact our office today at 816-203-0143 for free consultation or by filling out our online contact form. You can also instantly download our free guide for long-term disability appeals to learn more. Call us today, we’re here to help!