If your request for long term disability insurance benefits has been denied, you may be wondering what your next steps should be. All disability insurance carriers have an appeal process, whether this means a mandatory internal appeal or a civil lawsuit – however, the deadlines for these appeals can be tight, and just getting the ball rolling can seem like a major challenge. Below, learn more about the steps you’ll need to take to appeal the denial of benefits, as well as how the attorneys at Dell & Schaefer can help you present the strongest possible case to your disability insurance carrier.
Read Your Denial Letter to Spot the Due Date for Your Appeal
When your disability insurance claim is denied, your disability insurance carrier is required to provide a denial letter that explains why your claim was denied, citations to the specific sections of your plan on which the denial is based, a list or description of any additional information you can provide to further support your claim, and the deadline for your ERISA appeal of the claim denial. In most long term disability plans governed by the Employee Retirement Income Security Act (ERISA), the claimant has 180 days from the date of the denial to submit the disability appeal. Missing this deadline, even by just a day, may prevent the claimant from receiving any benefits.
Request a Copy of Your Disability Claim File
Along with requiring the insurance carrier to issue a denial letter explaining why your claim was denied, ERISA requires these carriers to provide claimants with a complete copy of their entire claim file. This copy must be provided at no charge and can range from hundreds to thousands of pages, including:
- The insurance carrier’s medical reviews
- All the disability claim forms you submitted
- All the medical records you submitted (or the insurance carrier requested and reviewed)
- A copy of your long term disability insurance plan documents
- Any internal emails or notes created by the insurance carrier
- Any reports of video surveillance
After a claimant requests a copy of their claim file, the disability insurance carrier will begin to prepare it; claimants generally should allow at least 30 days to receive this information.
Let Your Claim File Direct Your Strategy
Each disability claim is different, which means there’s no one-size-fits-all strategy when it comes to appealing a denial of benefits. In some cases, the reasons provided in the denial letter might not be backed up by the claim file; for example, your job duties may be misclassified or your medical records may be incomplete. The contents of your claim file, including the notes that show the disability insurance carrier’s review, can help you and your disability insurance attorney decide the best strategy to use and supplemental evidence to gather that can prove you’re entitled to disability benefits.
Get Additional Medical Support to Prove Your Disability
The most challenging (and time-consuming) part of your disability appeal can be working with your doctor and attorney to see what extra medical testing and treatment you may need. By going through additional evaluations and medical testing, you’ll be able to provide the disability insurance carrier with a more comprehensive picture of your restrictions and limitations.
In some cases, this may mean seeing a new doctor or different specialist to get further medical support of your claims. In other situations, more diagnostic testing (like an MRI, CT scan, X-Ray, or bloodwork), or non-medical testing (like functional capacity testing or a neuropsychological evaluation) can provide the necessary medical evidence to take your claim over the finish line.
Work on a Vocational Analysis or Labor Market Survey
To qualify for disability benefits, you’ll need to be able to show that you’re no longer able to perform the duties of your current occupation (the “own occupation” standard) or of any gainful occupation (the “any occupation” standard). Disability carriers tend to minimize claimants’ occupational duties and classify jobs as sedentary or light duty even when the reality may be different.
Although the disability carrier will lean on a “national economy” standard when assessing job duties, not the specifics of your particular job, claimants may be able to successfully argue that how they were doing their job was how it was performed in the national economy. To this end, it’s a good idea to prepare a vocational analysis or labor market survey that can show just how closely your job duties line up with the disability insurance carrier’s definition of “light duty,” “medium duty,” or “heavy duty.”
Work on Your Personal Statement
One helpful piece of documentation in your long term disability benefit appeal is the personal statement or co-worker statement. This statement should describe a typical day in your life and detail the reasons you can’t work full-time on a reliable and consistent basis. Your personal statement must be completely truthful; stretching the truth could get you in trouble down the line if your statement doesn’t line up with the disability insurance carrier’s observations.
In other cases, you may be able to get a statement from a former co-worker to describe your medical limitations and how they impacted your ability to do your job. Family members or others who observe you regularly can also submit statements on your behalf.
Draft Your Appeal Letter
The previous six steps make up the bulk of the appeal process. But your appeal letter is what brings it all home – it’s strategically-drafted to focus on why, under the terms of the long term disability insurance policy, you’re entitled to disability benefits.
Your appeal letter should be confined to the facts and read so that no reasonable person who reviews the appeal level will believe you can work full-time. Most appeal letters are dozens of pages long and include extensive detail, backed up with medical evidence and personal statements. Once you’ve finished this letter, submit it – along with the full appeal packet – to the long term disability insurance carrier by mail, with a verified return receipt.
We hope these steps have provided you with a starting point for the appeal process. At Dell & Schaefer, our experienced long term disability insurance attorneys have prepared thousands of disability appeals and can provide you with a free initial review of your claim. Give us a call today to set up your free consultation.