Having your long-term disability claim denied can be stressful and confusing. If this is an issue you are dealing with, you should take heart in the fact that most long-term disability claims are denied. This should not be surprising. Insurance companies make money by denying claims.
WHAT IS THE NEXT STEP?
You are likely required to file an administrative appeal. Appealing a denied long-term disability claim is not easy. However, a long-term disability appeal is a lot like a redo. You get a second chance to compile and present medical and vocational evidence to try to have your claim accepted. For many, the assistance of an experienced disability insurance attorney to navigate the process is essential.
ERISA Versus Non-ERISA Policies
The Employee Retirement Income Security Act (“ERISA”) governs many employer benefits including disability insurance. If your disability benefits are provided by your employer, ERISA likely applies. ERISA regulates most aspects of how disability claims are processed. This includes the timeframes for making a claim determination.
Under ERISA, when a claim is denied, an employee must appeal in accordance with the administrative appeals process. A policyholder cannot file a lawsuit for wrongful denial of the claim until the administrative appeals process has played out. The process of filing an administrative appeal can be time-consuming. In most cases, a policyholder will have 180 days from the date the claim has been denied to appeal. Only after the administrative appeal is denied can a policyholder file a lawsuit.
Non-ERISA disability policies are governed by state contract law similar to most all other insurance policies. There is no administrative appeal process. If your claim is denied, you can file a lawsuit.
The First Step: Making Your Claim
Even though you may have already received short-term disability benefits, this has little to do whether you qualify for long-term disability benefits.
For long term disability claims, your medical history and medical records are critically important. A policyholder must establish that he or she has a disabling condition. It is the policyholder’s burden to establish within a reasonable medical degree of certainty that a disabling condition exists and that the policyholder’s ability to work and earn wages has been impaired.
Long-term disability policies tend to either be “own occupation” and “any occupation” policies. Under “own occupation” policies, a policyholder is considered disabled when, due to an illness or accidental injury, he or she is unable to perform their current job. With this type of policy, the policyholder can qualify for benefits even if he or she can perform a job or occupation that is different from their “own occupation.”
This differs sharply from “any occupation” policy in which an applicant is disabled when he or she is unable to work any type of job. For example, under in any occupation policy, a contractor whose disability does not prevent him from working a light-duty job could not recover long-term-disability benefits.
Many long-term disability claims involve significant potential recoveries and it is not uncommon for insurance companies to aggressively litigate claims. Experts often take on a significant role in disability claims. If your claim is disputed, you need a qualified team of experts to help establish that you are disabled.
Disability claims first and foremost are driven by medical opinion. A policyholder seeking benefits has the burden of establishing that he or she has a medical or psychological condition that is disabling. As a rule of thumb, the condition needs to be objectively serious. If your condition is insignificant or ill-defined, you probably will not qualify. Further, your physicians or medical experts need to help establish that your condition impacts your ability to work. This issue can be tricky depending on whether you have an “any occupation” or “own occupation” policy.
Vocational evidence often comes into play in long-term disability claims. Vocational evidence is simply evidence related to your education, work experience, and ability to earn a living. In many cases, the insurance company may hire an expert to state that you can work your regular job, or, in the case of an “any occupation” policy, a different job. Similarly, an experienced disability attorney should retain a vocation expert to establish that the client is disabled within the meaning of the policy.
The strength of a vocational expert’s opinion regarding disability largely depends on your objective medical evidence. If you have not been evaluated by the correct specialists to establish disability, your claim will probably not be approved. This is why having an experienced long term disability attorney to assist you can be instrumental.
Why are claims denied?
In many cases, disability claims are wrongfully delayed or denied, causing hardship and stress to the policyholder. However, sometimes claims are denied simply because the policyholder did not present enough evidence with their initial claim. It is the policyholder’s burden to establish the existence of a disabling condition. Most disability claims are denied due to a supposed lack of supporting medical or vocational evidence. For example, a policyholder may present evidence that they have been diagnosed with fibromyalgia but provide no further information as to how it impacts their ability to work. While the fibromyalgia may in reality be a disabling condition, the fact the policyholder did not link their condition to vocational status may prevent their claim from being approved.
On the flipside, the insurance company is working hard with a team of experts to deny your claim. Most insurance companies have a list of preferred medical experts who they routinely send disability claimant’s to for evaluation. The insurance company’s experts will often differ sharply from your treating physicians and will almost always conclude that you are not medically disabled. While this is not fair, it is the way the disability process works. If you feel the insurance company is stacking the deck against you, you should consult with a disability insurance attorney.
When a claim is denied, the policyholder should be provided an explanation of the denial and information about how to file an appeal. By law, the policyholder should be advised of any deadlines for appeal.
A disability insurance company must provide the policyholder with a free copy of the entire administrative record kept by the insurance company. The record includes many types of documents that are relevant to your claim, including medical reports, surveillance photos and videos, vocational records, expert examination reports, and any other evidence that was used to deny your claim.
If you are dealing with a claim denial, we recommend that you obtain a copy of the full administrative record from the insurance company or plan administrator. You should present a copy of the record to an experienced long-term disability attorney who can evaluate your claim and discuss your options.
Tips for appealing a denied claim
First: Hire an Attorney. Appealing a long-term disability denial is a technical process filled with hard and fast deadlines and complicated rules. In most cases, a denied claim will be overturned only where there is a clear justification for doing so. An experienced disability attorney can assist you in presenting relevant evidence aimed at overturning the denial, or, pursuing the claim in litigation once the administrative process has played out. Many denials are overturned on appeal; however, your chances of a favorable outcome are slim if you do not take a different approach.
Second: Understand the Reason for Denial. The denial letter should specify why the claim was denied. It is important to attack the basis for the denial on appeal by gathering and obtaining relevant evidence. It is important to focus your arguments on appeal to attack the specific reasons why the claim was denied and submit supportive evidence.
Third: Understand the Insurance Policy. Insurance claims are governed by the terms and conditions of an insurance policy. Disability policies tend to contain numerous limitations and exclusions, which may be relevant to your claim. A plan administrator, by law, must furnish you a copy of the insurance policy. Once received, you should review it in conjunction with the denial letter to better understand why the claim has been denied. If the policy is unclear, or the denial seems to depart from the policy’s meaning, you should speak with an attorney to help you better understand the issues in your claim.
Four: Get Favorable Evidence and Tell Your Story. In many cases, a disability claim is denied because the policyholder did not present sufficient evidence to prove they are disabled. On appeal, it is important to build a record that will support your claim. In addition to compiling helpful medical and vocational evidence, a lot of times you can present additional evidence that helps prove you are disabled. For example, statements from friends and family members discussing how your disability has impacted you can help. You may have also done things like cancel vacations, gym memberships, and other items due to your medical problems. When appealing a denied claim, it is helpful to think outside the box and submit evidence that helps tell your story.
An administrative appeal gives you a second bite at the apple to try to have your long-term disability claim approved. You should not just assume that your appeal will be denied. Many denials are overturned on appeal. Your chances of success will likely depend on compiling the expert evidence needed to link your medical condition to the meaning of disability under you insurance policy.
If your long-term disability claim has been denied, you should speak with an experienced attorney to discuss what is needed to have your claim approved.