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A List Of Do’s And Don’ts For Appealing A Long-Term Disability Denial

If your long-term disability (LTD) claim is denied, it’s natural to feel frustrated and overwhelmed. However, a denial isn’t the end of the road. You can appeal a long-term disability denial, and many claimants successfully reverse denials through the appeals process.

Appealing a denial of a long-term disability claim for benefits under the Employee Retirement Income Security Act (ERISA) is both a right and an obligation. This means you have the right to appeal a long-term disability denial. However, under ERISA, you must go through all mandatory appeals directly with the insurance company before you have the right to sue it in federal court for its failure to pay benefits.

Thus, your submission of evidence during the appeal process serves two important purposes. First, the insurance company may consider the new evidence and approve your claim without suing the insurance company in court. Second, the evidence you provide during the appeal is often the only evidence you can use in federal court if your appeals are denied. In most cases involving an ERISA-governed long-term disability policy, the claim is closed once a decision is made on your final appeal. Any information you leave out may never be heard or considered by a federal court in litigation!

Disclaimer: Because every claim is unique, this list of “Do’s and Don’ts” is not exhaustive. It serves merely as a reminder of the most important things you should and should not do during an appeal. Another article discusses how to appeal a long-term disability denial in more detail. If you still have questions about how to file an appeal and what to include in it after reading these articles, you should consult a long-term disability attorney.

Do’s: What You Should Do When Appealing a Disability Claim Denial

  1. Do File Your Appeal Within the Time Limits. If your LTD claim has been denied or your benefits have been terminated, you must file an appeal within certain time limits. Your LTD policy specifically identifies the time limit. In most cases, you have 180 days to file the appeal.
  2. Do Obtain a Complete Copy of Your Entire LTD Claim File. Before you begin the appeal process, request your entire claim file and policy from the insurance carrier. You will be surprised at all of the information you will receive. The claim file should include your medical records, the insurance company adjuster’s internal notes, medical reviews by the doctor hired by the insurance company, surveillance video, and all other information the insurance company considered in deciding your claim. You must review all this information to know what to emphasize in your appeal.
  3. Do Obtain Medical Records From Any and All Treating Physicians. You should not focus only on the doctor treating you for your most serious or “main” disability. The more physicians you have giving opinions, the more likely your claim will be approved. The doctors should identify your limitations and restrictions and how your life has been negatively impacted by your illness/injury. You should get records from your family physician, specialists (such as neurologists, orthopedic surgeons, rheumatologists, cardiologists, psychologists, psychiatrists, etc.), chiropractors, physical therapists, and other health professionals who can opine on your ability to work.
  4. Do Supplement the Medical Records with RFC Forms From Your Treating Physicians. Medical records alone do not tell the story as to why you cannot work. It is very helpful to “bridge the gap” between your diagnoses and your resulting level of impairment. Your doctors should identify your level of impairment in a letter or by filling out a Residual Functional Capacity (RFC) form or Medical Source Statement.
  5. Do Tell Your Story. Personalize your appeal. You need to explain in detail why you’re unable to work. That’s why one of the most important components of an appeal, I believe, is your story. We typically do it in the form of an affidavit. We’ll send our clients a detailed questionnaire asking them about their daily lives, how long they can do certain activities before taking a break, and how long they need to take a break before they can resume those activities.
  6. Do Get Written Support From Your Former Employer. If you had to stop work due to an injury or illness, your medical condition may have impacted your work performance before you stopped altogether. Your employer should be able to give excellent insight into your ability to engage in work activity. Your personnel file should give a history of your performance reviews. Presumably, your only negative reviews would appear right before the end of your employment.
  7. Do Obtain Written Statements From People in Your Personal Life. A spouse, other family members, close friends, neighbors, pastors, or former co-workers can provide excellent insight into your daily struggles. They should speak to what they witness with their own two eyes. These people from your personal life should tell stories about the difficulties they’ve witnessed you have.
  8. Do Use the Decisions of Other Agencies Approving You For Disability Benefits. If you’ve been approved for State Disability, Worker’s Compensation, Social Security Disability, a disability retirement plan, CalPERS, or any other source of disability-related income, then an approval letter from these programs will be valuable evidence you can use to prove your inability to work to an insurance company.
  9. Do Confirm Receipt of Your Appeal. Insurers often claim they did not receive the documents submitted. For this reason, we always submit appeal packages with proof of receipt. We typically submit appeals by certified mail, fax, and, if available, email.
  10. Do Be Prepared for Surveillance. You should always be mindful of potential surveillance, but you should exercise extra caution if your insurer schedules you for an Independent Medical Examination (IME) or a Functional Capacity Evaluation (FCE) while your appeal is under review. The insurance company will know where you will be and when you will be there. Since insurers often carry out surveillance over a span of three consecutive days, it’s advisable to remain vigilant not only on the day of the examination but also on the day before and the day after. To minimize risks, consider having a friend or family member drive you to and from the examination, and aim to return directly home after the exam is completed.

Don’ts: What You Should NOT Do When Appealing a Disability Claim Denial

  1. Do Not Submit Your Appeal Immediately. Although you may be outraged upon receipt of your denial or termination letter, you should not rush to submit a simple appeal letter. Simply asking the insurer to reconsider is not sufficient. An incomplete or hastily prepared appeal is almost certain to be denied. Ensure you address all the reasons for the initial denial and provide ample evidence to support your claim.
  2. Do Not Submit a Simple Letter as Your Entire Appeal. The most important part of your appeal is the additional evidence you should submit with your appeal letter. Besides pointing out why you think the insurance company’s decision to terminate or deny benefits is wrong, you should submit updated medical records, opinion evidence from your doctors identifying how your medical conditions impair your ability to perform work activity (such as a letter, RFC form, or Attending Physician Statement), and more. Your appeal letter should be more like a cover letter, identifying why you disagree with the insurance company’s decision and enclosing the information that may change the insurance company’s decision.
  3. Do Not Submit Your Appeal Before Reviewing Your Entire Claim File. Unless you’re on a tight deadline, you should request your entire claim file and policy from the insurance carrier. You will be surprised at all the information you will receive. The claim file should include your medical records, the insurance company adjuster’s internal notes and memos, medical reviews by the doctor hired by the insurance company, surveillance video (if any), and all other information the insurance company considered in deciding your claim. You need to review this information so you know what to emphasize or if there are any inaccuracies you need to address in your appeal.
  4. Do Not Use the Generic Job Description for Your Position That May Be Provided by Your Employer or by the Insurance Company. In most policies, the definition of disability for the first two years is being unable to perform the material and essential functions of your individual occupation. Thus, if the job description the insurance company uses in its evaluation does not include a full and complete list of your actual duties, then your chances of having your claim approved go down dramatically.
  5. Do Not Ignore the Negative Side Effects of the Treatment of Your Disabling Medical Conditions and How Those Side Effects Impact Your Ability to Work. For example, the medications one takes for pain may make the claimant extremely fatigued. Another example is when an individual must undergo dialysis several times a week for several hours per session. Such treatments/side effects of a medical condition can have just as much of an impact on one’s ability to perform a full eight-hour workday as the underlying disease/injury itself. Your medical records should identify your medications and side effects, and you should make sure your doctors mention any medications or treatments and what side effects they have to the insurance company.
  6. Do Not Submit Your Documents by “Regular Mail.” You should use a trackable shipping method, such as Federal Express, Overnight Mail, or certified mail.
  7. Do Not “Appeal” or Discuss Your Case on the Phone. Do not attempt to request an appeal over the phone, and do not answer questions from the insurance company over the phone. You should request that all communications be in writing and submit your appeal letter using traceable forms such as certified mail, fax, or email.
  8. Do Not Go Past the Deadline to Appeal: In most cases, you have 180 days from the date on your denial letter to file an appeal. If you fail to appeal before the deadline, you may waive your right to pursue the claim further in court.
  9. Do Not Handle Your Appeal Alone If You’re Not Physically or Mentally Capable: Consult an experienced attorney. You can hire an experienced attorney, often on a contingency fee basis, which means you only pay a fee if the lawyer obtains benefits for you.

By following these do’s and don’ts, you significantly improve your chances of winning your long-term disability appeal. Always remember, when in doubt, consult an attorney to guide you through the complex appeal process.

Ortiz Law Firm Provides Aggressive Representation in the Long-Term Disability Appeal Process

Unfortunately, long-term disability carriers do not make it easy for disabled claimants to receive the benefits that they deserve. If your medical condition makes it impossible for you to work and you have been denied your long-term disability benefits, the legal team at Ortiz Law Firm can help you cut through the red tape and fight for your disability benefits no matter where you live in the United States. Call us today at (888) 321-8131 to discuss your claim with an experienced long-term disability attorney.