If you have faced an injury or medical condition that has rendered you unable to work, it can be a scary time. The uncertainty of your own health, compounded by wondering if you will be able to pay your bills, can be overwhelming.
Many individuals carry Long Term Disability (LTD) insurance, often times offered as an employer-provided benefit. The purpose of an LTD policy is to replace a portion of the disabled person’s lost income, typically between 50-70 percent. However, as is the case with a homeowner’s policy or auto policy, the insurance company isn’t simply going to hand over the cash without a determination that the person is disabled from performing the job duties of his/her specific occupation.
Once a claim is submitted seeking LTD benefits, it will be reviewed by an adjuster working for the insurance company. There are a host of reasons they may deny a claim, ranging from citing a preexisting condition, to determining that there is insufficient medical documentation to support the claim.
Receiving a denial letter rejecting a claim for benefits can be devastating, but it doesn’t mean it is the end of the road. Every individual has the right to appeal the decision of the insurance company. In fact, the appeal may be the best last chance to secure LTD benefits.
The strength of an appeal when an individual has been denied LTD benefits varies widely from person to person. Not everyone has strong grounds for appeal, but many do. If yours is a case with merit, you don’t want to go it alone. Like David battling Goliath, you will be facing off against a powerful adversary, the insurance industry. Knowing that they will fight to reject your appeal, you need someone on your side fighting just as hard to get you your LTD benefits.
Some individuals purchase their own LTD policies through insurance agents or trade associations, and there is a specific process to appeal a denial of benefits. However, the majority of employer-provided (group) LTD policies are governed by a federal law known as ERISA. Since that is the most common type of claim, it is what I am going to focus on here, although I have a depth of experience working with clients to successfully appeal both types of LTD coverage.
If an individual is denied benefits, the letter detailing the reason for the denial will also include a deadline by which any appeal must be filed. Once an appeal is filed, it will be reviewed by an appeals department of the same insurance company that denied the claim. A written decision either approving the claim, or denying it for a second time will be sent, typically within 45-60 days.
With both the application and the first level appeal, the decisions are reached based largely on the quality of the written materials and supporting evidence submitted on behalf of the claimant. This is why it is advisable to consult an attorney to assist with filing an appeal. The requirements are nuanced, the deadline is firm, and there is only one chance for that first appeal.
A properly written, thoroughly documented appeal can greatly increase the chances of a reversal of your initial denial for benefits at the administrative level. Once all administrative appeals to the insurance company have been exhausted, the individual must file a lawsuit, typically in Federal Court, to further challenge the denial.
If the appeal is denied, there may or may not be an opportunity for a second level review or appeal to the insurance company. Again, this is a complicated process and it represents an individual’s last best chance to reverse the denial of benefits.
While it is possible to navigate the process of filing a LTD claim and the subsequent appeals alone, many people choose to have an experienced attorney manage the process for them. These cases are handled most often on a contingency fee basis, meaning the attorney doesn’t get paid unless he or she recovers money for the claimant. That is an important detail because as a disabled person faces the challenges inherent with suffering a long-term disability, the last thing he or she needs is an added financial worry.
If you or a loved one has a long term disability claim, and you need guidance on the next steps, give my office a call. I can talk with you over the phone and assess the best course of action for your unique case to get you the most favorable outcome possible.
Harry J. Forrest is an attorney with Gross Shuman PC. He practices in the areas of civil litigation, business counseling and long-term disability claims and appeals. He has successfully handled cases in both federal and state courts and has tried cases to verdict involving claims for personal injury, property damage, contract disputes and constitutional civil rights violations. You can contact him at 716-854-4300 ext. 225 or email@example.com