Receiving a denial letter from an insurer for your long term disability claim can feel devastating, especially when you’re already dealing with a serious health condition that prevents you from working. However, a denial does not mean the end of the road. Insurance companies often deny many legitimate claims initially, but may ultimately pay out benefits if a proper appeal is filed. It is important to understand that you have several options to fight back and potentially secure the disability benefits you deserve.
The information below highlights important steps to take if your long term disability claim was denied.
Reasons Why Long Term Disability Claims Get Denied
Before diving into the next steps you should take following a claim denial, it’s important to understand common reasons why long term disability claims are denied. In many instances, insurance companies will point to the following reasons to support their denial:
- Insufficient medical evidence
- Disagreement with your doctor’s assessment
- Surveillance evidence suggesting you can work
- Technicalities like missed deadlines or incomplete paperwork.
There are even instances when the insurance company will try to argue that your condition doesn’t meet their definition of disability or that you could perform other types of work. Understanding the specific reason for your denial will help shape your response strategy.
Review the Denial Letter Carefully
One of the first steps you should take following a claim denial is to thoroughly review the denial letter. This document contains crucial information about why your claim was denied and outlines your appeal rights. Pay close attention to the specific reasons cited, the deadline for filing an appeal, and any additional documentation the insurance company claims is needed. The denial letter should also reference specific policy provisions or medical standards they believe you don’t meet.
Take note of any factual errors in the letter, such as incorrect medical information, wrong dates, or mischaracterized job duties. These mistakes can be important evidence in your appeal. Also, check if the insurance company properly considered all the medical evidence you submitted or if they appear to have overlooked key documentation.
Compile Medical Evidence
One of the most common reasons for long term disability claim denials is insufficient medical evidence. Start by requesting all medical records related to your condition from every healthcare provider you’ve seen. This includes primary care physicians, specialists, hospitals, physical therapists, and mental health professionals.
Work with your treating physicians to ensure they understand the insurance company’s definition of disability and can provide detailed reports supporting your claim. Ask them to specifically address your functional limitations and how your condition prevents you from performing your job duties or any occupation. Objective medical evidence like imaging studies, lab results, and standardized tests carry significant weight.
Consider seeking additional medical opinions or consultations if your current medical records don’t fully capture the extent of your disability. Sometimes a fresh perspective from a specialist can provide the detailed functional assessment needed to support your claim.
Document Daily Limitations
Insurance companies want to see how your condition affects your daily activities and work capacity. Keep a detailed diary documenting your symptoms, limitations, and how your condition impacts your ability to perform basic functions like sitting, standing, concentrating, or lifting objects.
Include specific examples of how your condition prevents you from performing your job duties. If you’re a teacher who can’t stand for long periods due to back pain, document this. If you’re an accountant whose cognitive symptoms prevent concentration, record specific instances where you struggled with tasks that were previously routine.
Understand Your Appeal Rights and Deadlines
Most long term disability policies provide appeal rights, typically allowing 180 days from the denial date to file an appeal, though this can vary by policy. For ERISA-governed plans (most employer-sponsored plans), you generally have 180 days. Missing this deadline can permanently bar your claim, so mark your calendar immediately.
Some policies allow multiple levels of appeal, while others may only provide one opportunity. Understanding your specific appeal process is crucial because ERISA plans typically require you to exhaust all administrative remedies before you can file a lawsuit.
This is the single most important thing that insurance companies hide from beneficiaries: If you appeal and you are denied in most cases the record will be sealed forever. Your only hope will be to go to federal court where you cannot take testimony or add any evidence and in many cases the judge can only overturn the decision if it was irrational, not just because it was wrong or the judge truly believes you were disabled. This is why the time to seek professional advice is before you appeal as an attorney may not be able to help you without that vital appeals period to review the file and correct any errors in it.
Consider Hiring a Long Term Disability Attorney
Long term disability law is complex and the appeals process can be intimidating. This is where having an experienced and knowledgeable long term disability lawyer on your side can pay dividends.
A lawyer can help you effectively navigate the complexities of the appeal process, gather appropriate medical evidence, and present your case in the most compelling way possible. As noted above, if you do not consult with an attorney before filing an appeal of a denial, many attorneys may not be able to help you. An experienced attorney with Bross & Frankel also knows common insurance company tactics and can help you avoid potential pitfalls.
Preparing an Effective Appeal
The appeal should address every reason cited in the denial letter while providing additional evidence to support your claim. Once again, this is where having the guidance of an attorney can be beneficial. Make sure to include updated medical records, detailed physician statements, and any new test results to help bolster your claim.
If the insurance company conducted an independent medical examination or file review, consider having your own medical expert review their findings and provide a contrary opinion.
Make sure your appeal is filed well before the deadline, preferably by certified mail or another method that provides proof of delivery. Keep copies of everything you submit and maintain detailed records of all communications with the insurance company.
After your appeal is filed, the insurance company will likely respond within 45-90 days, depending on the complexity of the case. It is also important to note that, under many ERISA policies, only a single appeal is allowed and must be filed within 180 days from the date of the initial denial.
What To Do If Your Appeal is Denied
If your appeal is denied, you have additional options depending on the type of insurance policy. For ERISA plans, you have the right to file a federal lawsuit, but you’ll generally be limited to the evidence in your administrative record, making your options very limited if your appeal did not include everything that could possibly support your claim through an “arbitrary and capricious” review. A thorough appeal before you get to this point is crucial. For non-ERISA policies, you may have broader options such as filing a lawsuit in state court. An experienced attorney can help evaluate your options and develop the best strategy for your specific situation.
Contact an Experienced Long Term Disability Lawyer Today
Do not wait until after you appeal! Dealing with a denied disability claim is challenging, but persistence often pays off. The key is acting quickly, gathering strong medical evidence, and presenting a comprehensive case that clearly demonstrates your disability and its impact on your ability to work.
If your long term disability claim was denied, do not give up hope. Take action by contacting Bross & Frankel’s ERISA long term disability attorneys today. Our team of skilled long term disability lawyers possess the experience and knowledge necessary to address the insurer’s reasons for denying your claim. We’ll get to work to give your appeal the best chance of success.
If you have been denied long term disability or your benefits have been terminated, or if you have questions about how to apply for benefits, contact our attorneys today to schedule a case evaluation.