Hi, I’m Nick Ortiz. I’m a Florida disability lawyer, although I’m licensed to practice in Florida, California, and Texas, and I can handle cases nationwide. Today I want to talk to you about why it takes so long to file a long term disability appeal. This is both for my existing clients and for anyone out there who may be considering hiring us.
You are given 180 days by law under ERISA, the Employee Retirement Income and Securities Act of 1974. So you’re given 180 days by law. And then you will see in a denial letter, usually at the very end of the letter, the insurance company will say, “If you disagree with our decision, you must file an appeal with us within 180 days.”
But why so long? For most people, an appeal is just a letter saying, “Hey, we think you got it wrong. We want you to go back, take another look at it, and make a new decision.” That will never work in terms of getting them to change their decision.
You have to give them new evidence to get them to change their mind. So I’m really going to break down for you today everything that goes into an appeal and why you might actually need a good portion of those 180 days.
Another reason why I’m doing this video is because we recently had a client who was really pushing us. He couldn’t understand why it was taking so long to get his appeal out. And by so long, I mean about 60 to 90 days. I will break down why it can take us the full 60, 90, 120, even up to 180 days to get an appeal out.
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So, the first thing we do when we get a case is request the claim file. So, in your denial letter, it will usually say, “You have the right to request a copy of your claim file.” That includes everything that’s been done in your case, all the correspondence. It can typically be anywhere from 200 to over 1000 pages long. It can include your insurance policy, communications to and from doctors, medical records, and internal correspondence with the insurance company. But it has everything that pertains to your case. They have up to about 30 days to get it to you.
So once we get the claim file, let’s say it takes about 30 days, then we break it down and try to determine what’s in the file. We really have to determine what medical records are already in there to reverse engineer what medical records we need to get.
At the same time, while we’re waiting for the claim file to come in, we may send out a round of updated medical records requests to all of your doctors to make sure that we have a complete set of medical records, because the most important part of your case is your medical records. We try to do that at the same time as the claim file request so that both of those things happen simultaneously.
We used to request the medical records after we got the claim file, but it took so much time that we decided to start requesting them at the beginning of the case. It takes the doctor’s office anywhere from a few days to several weeks to process our request for records. So again, that’s more time. Typically, it takes 30 to 45 days to get all the medical records together.
Another thing that we do is we try to break down your insurance policy. The insurance policy governs everything, and it determines what your rights and responsibilities are. We have to determine how they define the terms disability and occupation, and we have to look at what your occupation is and what your duties and responsibilities are. We really have to break down what it is you have to prove under your own individual policy so that we can determine how to approach the appeal.
One of the other things we need to do is determine whether or not we need to attack the vocational aspects of your case. That’s the vocational analysis of your case. So they may have said in your letter, “We think you could be a security guard, or a receptionist, or that you could work “at an information booth handing out informational brochures.”
So, we may have to hire a vocational expert to determine whether you could do those types of jobs or other jobs based on what they see in the medical records and based on any opinions that your doctors have provided. So that’s another thing.
In addition to your actual medical records, we may need to get what we call opinion evidence from your doctors. You’re probably most familiar with this when the insurance company sends you what’s called an attending physician statement. The attending physician statement asks the doctor about what kind of limitations you have as a result of your medical condition.
When it comes to the attending physician statement, we don’t like to just use their generic one. We like to use a form customized with respect to your individual conditions. It goes into a lot more detail and tries to identify your specific limitations. So it takes a little bit more time to communicate with your doctors and get that evidence together.
In our office, we’ll typically create an affidavit, which is your sworn statement, which is evidence that can be used under penalty of perjury. It’s notarized. And it basically states what your limitations are from your own point of view. So we send you a very detailed questionnaire that breaks down what your limitations are on a day-to-day basis so that we can use that to show why you can’t do the work activity.
Once we get all that information together, then we have to do the legal analysis. So we have all of the evidence to use, but then we have to break down the denial letter to determine what kind of legal errors we’re alleging that they made. So there’s some issue spotting trying to determine what the insurance company said, how it was improper and/or illegal, or legally insufficient, and attacking each of the legal errors that they made.
So we combine the law with your facts and we do a very detailed legal analysis of all the errors that we think they made and why we think the decision should be reversed. And that, in and of itself, is usually between 14 and 20 pages, which is the average length of our appeals, where we summarize all of the medical, all of the vocational, and all of the legal analysis.
That whole process, as you can tell from everything that I’ve said, can take anywhere from 60 to 90 days on average for our office. It can take even longer in some cases if we’re having trouble getting medical records and expert testimony. It can be a little bit faster if there are not as many doctors that we have to deal with. But that’s the average length of time that it takes.
I’m also trying to show you that there’s a lot that goes into filing an appeal. So if you want to do it on your own, you can do it on your own. You don’t have to have a lawyer to help you. However, if you would like the assistance of an experienced law firm like ours, we encourage you to call us at (888) 321-8131.
If you’d like more information, I’ve also written a book called The Top 10 Mistakes That Will Destroy Your Long-Term Disability Claim. I encourage you to download a free copy of this digital book, and we look forward to hearing from you.