Long Term Disability Law Blog
There are many reasons to file a strong appeal to the Reliance Standard insurance company. Every disability insurance policy holder needs to know how to strengthen their claim in the event it is denied and a lawsuit must be filed.
GREG DELL: Hi, I’m Greg Dell, here with attorney Alex Palamara. And Alex, I want to talk to you about reliance standard ERISA disability appeals. And the reason I say ERISA is because I’d say 99% of the long-term disability appeals we do with Reliance are ERISA, because they write group disability policies. And people who get the Reliance policy have it as an employee benefit.
So we’ve handled hundreds of claims against Reliance Standard. And I kind of wanted to do, in this video, a how-to, kind of tips for people, who need to file an appeal, so that they have an understanding of what’s involved in filing an appeal, and why it’s in their best interest to have a lawyer help them, and what the consequences are of doing the appeal on your own, and then getting a lawyer later.
So the first thing is that, why is it so important to submit a strong appeal right now?
ALEX PALAMARA: Your appeal is the last opportunity to strengthen your claim for a lawsuit. Once Reliance Standard denies your appeal, you cannot submit any more information into your claim. So, what I’m saying is, once they issue a final denial, that information that’s in the claim vault at the time of the final denial is the information that’s going to be presented to the judge.
Let’s just say there’s medical documentation of an MRI, or whatever testing that you had done, but that you did not submit with your appeal prior to the final denial. The judge will never see that information. So your appeal is – the purpose of an appeal is twofold. One, to get you back on claim. And two, to strengthen your case for the potential lawsuit that’s coming down the road.
GREG DELL: OK, so, if you submit an appeal, and the disability company makes a decision, and the next day the claimant loses their leg, is the court going to be able to consider that?
ALEX PALAMARA: Never. I mean, you can get hit by a bus, become a paraplegic, the judge will never be able to consider that information.
GREG DELL: OK, so, that is highly unusual in any other area of the law, because you have to get every single thing in or it’s never going to be considered. The other thing that we do that’s unique is, when we send our request – the person gets denied, they hire us, we request the claim file.
The claim file is every single thing that Reliance Standard relied upon to deny the claim. They have to give it to us. That’s one positive of a ERISA, because in other lawsuits, we spend a year litigating through what’s called interrogatories, requests for production, requests for admission, send us this, send us that. Finally, we get everything. Here, we get it all within three weeks.
ALEX PALAMARA: Correct.
GREG DELL: Right? You get this claim file now. What’s the first thing that’s most important in the preparation of an appeal?
ALEX PALAMARA: Well, most claim files could be anywhere from 500 to thousands upon thousands of pages. So you’re looking for a needle in a haystack. And the most important thing you’re looking for are the reviews that Reliance Standard conducted on your claim. Because what they’re hanging their hat on to deny your claim are these reviews.
Sometimes, they’re independent physician reviews, where an independent physician conducts a paper review, or essentially they look at the medical records of your claim, and they give an opinion as to whether you’re disabled or not. Sometimes, it’s the report from an independent medical examination or a functional capacity evaluation.
But more often than not, what they typically do is, they rely upon these, quote, unquote, independent physician reviews. And the first thing you want to do is locate these reviews. They’re anywhere from three to 10 pages long on average. And if the claim file’s a thousand pages, you have to find that needle in the haystack.
GREG DELL: Why is the medical review done by the insurance company your starting point?
ALEX PALAMARA: Because, again, that’s what they’re hanging their hat on to deny your claim. And you want to find these reviews so you can literally poke holes in the reviews. Find issues what with what they – issues with their conclusions, issues with the medical documentation that they’re citing to, or the medical documentation that they’re overlooking.
GREG DELL: OK, so we get the medical reviews. What we have to do then is analyze their medical reviews, analyze the medical records that are already in your file that have been sent. And then, we get together and we strategize as to what additional medical evidence can we obtain that is going to convince this disability company that you’re disabled.
And the way we do that is, number one, from our experience of having handled thousands of these claims, we know for almost every medical condition what the additional medical support is.
The other thing we do is, we take the medical file reviews that you were just discussing, and we provide them to either your treating physicians to review and opine upon, or we’ll go out to consulting medical experts that we’ve worked with all over the country, and say, here are the medical records of our client, here’s the medical reviews from the company, what do you suggest is missing here?
And what is the best way for us to attack this to prove, undisputedly, that our client is disabled, has restrictions and limitations as a result of that medical condition? Talk about our specialty in working with attending physicians and other experts to obtain a unique attending physician statement from a treating doctor.
ALEX PALAMARA: In most cases, we draft a specific attending physician statement that’s specific to our client’s disabling condition and specific to our client themselves. So we go out there and we write a few page report of questions that we present to the treating physician. We’ll get your physician on the phone with us.
We’ll explain to them the situation. Sometimes, they wish for us to send a fax or a letter to them. So we’ll put together a one or two page cover letter, explaining this whole situation, what the definition of disability is, what the insurance company has said.
We’ll provide the review that the insurance company conducted on your claim. And we’ll have very general questions, or very kind of basic questions, that your doctor can easily answer and give support for your claims. So we’re going to go out of our way to make sure that your doctor not only speaks to us, but responds and fills out that attending physician statement that we’ve drafted for him or her.
GREG DELL: OK, so the first, most important thing you got to do is get the appropriate medical support, and address it in a manner where you are making your medical condition accepted by the insurance company.
The next thing, which is rarely done by the insurance company, is presenting the occupation. And how important is it in your appeals in building up what the occupation is based upon the definition of disability in that person’s policy?
ALEX PALAMARA: Well, what the insurance companies love to do is, they’d like to take the – let’s just say you are a driver. And they don’t get very specific. They go to the Dictionary of Occupational Titles, say, yeah, you were a driver. The Dictionary of Occupational Title says it’s a sedentary job, you only sit all day.
Well there’s different levels of driving. You can be a delivery driver, where you’re carrying things out of the back of a truck, which is a very heavy level job. So they kind of dumb it down, to the point where they’re kind of dumbing down your occupation and overlooking many of the requirements that your occupation has.
So sometimes we’ll work with a vocational expert to actually explain the requirements of your job. So that when we file the appeal, the insurance company can no longer dumb down your occupation to make it seem like it’s a lesser job than it actually is.
GREG DELL: Right, and then the other thing we’ll do is, we’ll go to great lengths to have – work on what’s called a personal statement, slash, occupational description, to really go through a day in the life of your particular job. You don’t just go to work, if you had a sedentary job, which is like a desk job, and just sit there and do nothing.
Obviously, you have qualifications and experience for that job. And if you’re having limitations, or pain, or difficulty multitasking, or focusing, or any of those things, you can’t do that. And we have to portray to the disability company that your job is far more than just this sedentary task.
ALEX PALAMARA: Right, and Reliance Standard loves to deny claims saying, oh, look, your doctor said, or our doctor said, you can sit for eight hours a day. But there’s more to a sedentary job than just sitting there all day, as everyone knows.
GREG DELL: And then once you establish the medical and you establish the occupational, how important is a personal statement, statements from co-workers, statements from family members?
ALEX PALAMARA: The thing about these ERISA laws that govern these claims, is that the one thing they did was, they took away testimony. You’re never – if you have to file a lawsuit, you’re never going to be able – you’re never going to be afforded the opportunity to testify in front of the judge, so the judge can hear out of your voice what you suffer from on a daily basis.
What your life was before you’re disabling conditions, what your life was while out on disability, what your life has been since you’ve been denied disability benefits. And the judge will never be able to hear from your friends, and family, and co-workers, who’ve seen you suffer over the years.
So writing personal impact statements is the only time that you’re going to actually be able to testify to the judge. It’s going to be in the claim. If we submit it with the appeal, it’s going to be in the claim file. And it’s the only time the judge is ever going to be able to see what your own thoughts are, what your family’s thoughts are.
So, essentially, it’s your only time you’re going to be able to testify for your claim. So it’s very important for the judge to be able to see it. Because the judge has to review it. If it’s in the claim file, the judge has to review it. So it’s so important to do personal impact statements.
GREG DELL: And then some of our claims will also want to do a recorded statement of the claimant, or have them do a video of themselves showing what’s wrong, sending pictures in of whatever the potential condition would be, especially someone who has physical manifestations of their condition.
And doing these videos that we work with people to produce, to show like, this is my testimony, this is my statement, to humanize what’s going on with the claimant. Because they only look at your claim on paper.
ALEX PALAMARA: Right.
GREG DELL: So you have this calculated effort of you’ve got to put in the medical, which is – we minimize it here, but it’s a tremendous task to get that medical done appropriately. A lot of doctors don’t want to cooperate. And we’re very good at working with them, and if not them, getting the appropriate expert.
Working on putting in your occupational description through working with an occupational expert if we need one, or putting in our own occupational study from studies that have been done about the occupation, case studies about the occupation.
Again, also in the medical, we’ll put in tons of medical literature to show how people who have this condition have difficulty returning to work. And the last thing is the personal statements from you, from friends, from family, from employees. And then putting this all together. You have everything.
Now, why do people want to tell the insurance company what they did wrong in the appeal, and do you agree with that?
ALEX PALAMARA: Why do people want to tell the insurance company? Because they think that just telling them what they did wrong– oh, you got my claim wrong, please review. I’m filing this appeal. Obviously, you got my decision outcome wrong, because I can’t work anymore. And they think that’s enough. You have to go beyond that.
You have to prove it to them that you’re disabled. Knowing that you’re disabled is not enough. You have to prove to the insurance company that you’re unable to perform the duties of your own occupation or any occupation. And you do that with the medical records.
You do that with the physician support. You do that with the personal impact statements. And you can do that by tearing apart the reviews that the insurance companies are relying upon. You can’t just say I appeal.
I see so many times where people come to me to file a lawsuit for them, and they did their own appeal. And I take a look at their appeal, and their appeal was literally three lines long.
GREG DELL: Right.
ALEX PALAMARA: And I do the best I can with the lawsuit, but their lawsuit is nowhere near as strong as a lawsuit of an appeal that I filed.
GREG DELL: And then the last thing is, we want to really make sure they’re prepared, if you lose, that you have the best possible chance of winning in a lawsuit. So, we want them to review all the new evidence, but at the same time, we’re not going to give them the roadmap as to how to evaluate the claim appropriately.
Because the standard review is, did the company act unreasonably? Not did they get it wrong, but was it unreasonable? And if we give them a roadmap as to how to do everything right, like many lawyers do when they submit appeals, which are – those appeals might look good to a layman who’s reading them, but they’re terrible. And I bet you those lawyers don’t win a lot of those appeals. You can’t give them the roadmap.
So, let’s talk about your claim with Reliance Standard if you need to file an appeal. Please call Alex or myself or any of our disability lawyers. We help claimants all over the country. We always offer you a free initial consultation and review of your claim denial. And we look forward to the opportunity to speak with you.