If you or a loved one have recently received a denial of your long term disability (LTD) benefits, don't give up. At our long term disability law firm, we know first-hand how unfair and unfounded some LTD denials can be.
All long term disability policies allow for at least one and sometimes two administrative appeals. An administrative appeal is often required to overturn a wrongful denial of long term disability benefits.
ERISA Requires “Exhausting” Your Appeals
If your long term disability plan is a group plan purchased by your employer, it's likely governed by a federal law known as ERISA (the Employment Retirement Income Security Act).
ERISA is a federal law that prevents you from filing a lawsuit against the insurance company unless you have already exhausted all your administrative appeals. This means that you have to first appeal your denial through the insurance company’s administrative appeals process. You're allowed to proceed with a lawsuit in federal court only if your denial is upheld on appeal.
If your long term disability plan is not governed by ERISA, you may be able to simply file a lawsuit instead of filing an administrative appeal. It will depend on what the policy says and the laws that apply. An experienced long term disability attorney will be able to review your policy and advise what to do next.
ERISA Benefits LTD Insurance Companies
ERISA has certain rules that make it difficult for claimants and more beneficial for insurance companies.
First, in most ERISA cases, the standard used to review denials is known as the “abuse of discretion standard”. This standard provides insurance companies with the "benefit of the doubt" in making their coverage decisions. Basically, even if the insurance company was wrong about your denial, their denial still may be upheld in court if their processes in reaching that conclusion was "reasonable."
Second, you must submit any and all information to support your claim in your appeal. The reason is ERISA prevents LTD claimants from submitting additional evidence later if it was not originally included in the administrative appeal. If you forget a key piece of evidence, there will be no way to fix it later.
Third, ERISA allows your insurance company to set short deadlines by which you must file your appeal. Your denial letter must detail the number of days you have to file an appeal. Most policies we encounter allow 180 days to file an appeal, but you should read your denial letter closely because this time could be shorter or longer depending on your policy. These are hard deadlines, so you do not want to let them pass or your right to appeal will expire.
How to Appeal an ERISA LTD Denial
1. Read the Denial Letter. The first and most important step in appealing your long term disability denial is to read your denial letter. You need to understand exactly why your claim was denied and what information you need to submit. For instance, if your claim was denied because of lack of objective medical evidence of your disability, you need medical evidence from your treating physicians that supports your limitation. If your claim was denied because the insurance company says you can work in another job, you may need the assistance of a vocational expert.
2. Request Your LTD Claim File. The second thing you should do after receiving your denial letter is you should request, in writing, a copy of your claim file from your long term disability insurance company. The insurance company is required to provide you with a free copy under ERISA. These claim files can be quite voluminous, many times over a thousand pages in length. You will want to review these documents to again understand why your claim was denied and what, if anything, needs to be added.
3. Submit All Supporting Information in the Appeal. As mentioned above, ERISA bars you from submitting additional information after the administrative appeal. As a result, it is critical that you you should submit in your appeal any and all information possible to support your right to receive long term disability benefits. This means that if you need an opinion from your doctor, from a vocational expert, or reports from friends and family, you must submit it and anything else as part of your appeal. If you do not, you will likely be barred from submitting any further information later.
4. Consult with an Experienced Long Term Disability Attorney. Perhaps most important, if you have been denied long term disability benefits, we strongly recommend that you consult with a long term disability attorney who is trained in ERISA. ERISA claims are complicated legal matters. Very few attorneys handle these sorts of claims.
While there are certain legal matters you may be able to handle on your own, ERISA claims are usually not one of them. Even federal courts agree that ERISA claimants should not try to handle these claims without a lawyer because of the complexity involved. ERISA’s rules are not geared toward helping claimants but to protecting the decisions of insurance companies, and there are so many ways to make mistakes that will harm your claim.
Call our Kansas City Long Term Disability Attorney
ERISA appeals are difficult, but don’t give up. If you are overwhelmed by all this information, just pick up the phone and talk to an experienced long term disability attorney about your claim before filing your appeal.
Our Kansas City long term disability appeal attorney stands ready to assist you, to answer your questions and to provide guidance as to next steps to get your benefits reinstated. Call us today at (816) 203-0143 for free, no obligation consultation. We would be honored to assist you with your claim and appeal.