Navigating the complexities of a long-term disability denial can be overwhelming. After facing a denial, understanding how to request your claim file and policy is crucial. Reviewing your claim file is essential to gain insight into the reasons behind the denial and to explore potential avenues for appeal. This guide will walk you through the steps to effectively request your claim file and policy after a long-term disability denial and what to do if your insurer fails to provide it.

How to Get Your Claim File and Policy

When it comes to appealing your long-term disability claim denial, obtaining a copy of your claim file and policy is a crucial first step. By getting a hold of these documents, you can gain clarity on your insurance policy’s terms, conditions, and coverage and the evidence the insurance carrier considered before deciding your claim. Here’s how to request your claim file and policy.

Contacting the Insurance Company or Employer

To get a copy of your claim file and policy, contact your insurance company or your employer’s HR department in writing. Make sure you specifically request the Summary Plan Description, a full copy of your disability insurance policy that outlines the specifics of your coverage, and your complete claim files. You can itemize the specific aspects of the claim file you wish to receive to help ensure you receive the complete document, such as:

Medical records
Medical reviews
Investigative reports
Internal and external correspondence
Attorney or legal department review documents
Any other hard copies and electronically generated or stored copies of documents that reflect the administrative review process and procedures used by the insurance company and its representatives relating to your claim and any prior appeals.

In our disability insurance appeal guide, we provide a letter template you can use to request your claim file and policy.

Understanding Your Rights

ERISA Claims

Under the Employee Retirement Income Security Act (ERISA) and other relevant laws, you have the legal right to access your claim file and policy. The insurance company must provide you with a copy of your entire claim file and policy within 30 days. ERISA provides a penalty of $110.00 per day if your insurer fails to provide the claim file and policy within a reasonable time. If you do not receive all the documents you request within a reasonable time, you can file a subsection (b)(2), (a)(3), and § 502(c) lawsuit seeking the statutory penalty.

Non-ERISA Claims

You probably won’t have enough time to get your claim file from the insurance company before your appeal deadline (and unlike an ERISA policy, the insurer may not be required to provide it), but it’s still worth sending a request.

Next Steps After Obtaining Your Claim File and Policy

If you believe there are legitimate grounds for overturning the decision, you can consider appealing the denial. In some cases, pursuing litigation may be necessary to fight for the benefits you are entitled to. Understanding these options and their implications is crucial in making informed decisions that align with your best interests. An experienced attorney can help you navigate complex legal language, assess the strength of your case, and help you determine how to move forward. They can also assist in evaluating the reasons for the denial and strategize to appeal the decision effectively.

Discuss Your Claim with a Long-Term Disability Attorney at Ortiz Law Firm

Requesting your claim file and policy after a long-term disability denial is crucial in the appeal process. By obtaining these documents, you empower yourself with valuable information to potentially appeal the denial or seek further assistance from a long-term disability attorney. If you want to discuss your long-term disability denial and how we can help you appeal the denial, contact us online or call (888) 321-8131.

How To Get Your Claim File And Policy After A Long-Term Disability Denial

Table of Contents