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ERISA Long Term Disability Appeals

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Receiving a denial letter from your Long Term Disability (LTD) insurance company can be frustrating, frightening, and maddening all at the same time.

How can they deny your claim? You know you are disabled. You suffer from your disability every day. You treated with all possible doctors, gathered all of the medical records necessary and presented it to them. Yet an anonymous claims administrator decides that you are not disabled.

Whether the claims administrator had a legitimate reason to deny your claim or not, you must now gather yourself and prepare to fight the wrong denial.

Why long term disability applications are denied

Why long term disability benefits are terminated

Appeal Your Long Term Disability Denial

What’s next is an appeal of the insurance company’s denial. This is probably the most important step of the whole process. There are strict timelines and rules covering LTD appeals. What you do here determines how successful the appeal is, and if necessary, the subsequent lawsuit.

It is said that these cases are “won or lost at the appeal stage.”

Is Your LTD Plan Covered By ERISA

If your LTD plan was provided to you by your employer, as a benefit for working there, it is likely covered the Federal Employee Retirement Income Security Act (ERISA). ERISA trumps most state laws so there are certain features that are required.

You Must Appeal The LTD Application Denial First

Before filing a lawsuit, you must exhaust all administrative remedies first. In order to find out what these requirements are, you need to review the plan documents. There may be a Summary Plan Description (SPD) but I prefer to obtain and review actual plan documents.

In all cases, at least one appeal is required before you can go to court. Some plans will actually require two appeals before you can seek justice in federal court. Still, there are some plans that will require one appeal, but then offer a second “optional” appeal.

Again, it’s best to review the plan documents.

Deadlines to file appeals in LTD cases

There are deadlines you must adhere to, to ensure successful prosecution of your claim. In general, you have 180 days from the date of your denial letter, to file an appeal. Some plans will allow a longer period to appeal the denial.

That sounds like a lot of time, but it isn’t. Again, your case is mostly won or lost at this stage. So you must do everything you can to ensure your appeal is timely, accurate, and complete.

Some plans allow a second level appeal, and these time limits are even shorter. These deadlines serve as de facto statutes of limitations. They severely limit your chance of success if you fail to meet the deadlines. You absolutely cannot waste a single day.

What you submit in your LTD appeal will determine your case

If you lose your appeal, you will be forced to file a lawsuit in federal court. But there will be no trial, at least not in the usual sense. There will be no jury. Most importantly there will be no additional evidence.

The court will not consider any new evidence, except what has been submitted in the application and appeal. This is what is called the “administrative record.” If you have information that will help your case, but you failed to include it in the appeal, the court will not consider it.

It could be the smoking gun, the bombshell, the “coup de grâce.”

Doesn’t matter. The court will not review it, or consider it. It’s as if it doesn’t even exist. That’s why it is so important that your appeal be well thought out, complete, and persuasive. If not, the already stacked deck will be even more stacked against you.

Objective Evidence vs Subjective Evidence

When gathering your medical records, the burden is on you to prove your disability. Most policies will require “objective evidence.”

Objective evidence is evidence you can evaluate. For example, X-rays, blood tests, physical observations such as bruises. Any qualified person can take this evidence and evaluate it.

Subjective evidence cannot be evaluated. For example, if you say your foot hurts, nobody really knows if your foot hurts except you. Subjective evidence can be backed by objective evidence. If your foot hurts, and an X-ray reveals a fracture in the foot, then it validates your subjective complaints.

While some medical conditions are accepted without any objective  evidence (tinnitus for example), most cases will require objective findings and evidence. The more objective evidence you can provide, the stronger your case.

Read here for more information about objective evidence in LTD Claims.

Long Term Disability Appeal Process

You should consider contacting Disability Legal Center to handle your appeal. You may contact us via telephone or using the Contact Form on this website. You will receive a free consult with a licensed, California attorney, who will answer all of your questions.

The first steps to appeal the LTD denial is to request your claim file, and then review the denial letter.

Requesting your LTD Claim File

ERISA requires the insurance company provide your claim file within 30 days of a request. We do this immediately, as there is only 180 days for the appeal.

Once the claim file is received, we scan and then index the complete file. The file could be hundreds or even thousands of pages. It’ll consist of all of the medical records and reports they received, a copy of your LTD policy, your application for benefits, internal notes from the claims administrator, and correspondence.

Preparing the LTD Appeal

This is the most important step in your case. Again, the court will only consider evidence submitted in the application and appeals process, the “administrative record.” This is the time to pack the record with as much evidence as you can.

You will not have a chance to add any records after. It is your last chance to submit information and medical evidence proving your disability.

This is where we submit the appeal letter, along with any updated medical records, including Physician Statements and Functional Capacity Exams we have doctors complete.

Surveillance By The LTD Insurance Company

Keep an eye out for the insurance company’s spies. If your claim is a large one, then insurance company may spend a few thousand dollars to hire a private investigator to follow you around and record any activity that contradicts your claims of disability.

It is legal, and accepted by the courts. The videos themselves can hurt you.

Read more about surveillance in ERISA LTD cases here.

The LTD Appeal is accepted, or denied

LTD Insurance Companies have 45 days to decide your appeal. But they can extend this another 45 days if they send a letter explaining the special circumstances requiring the extra time.

If they accept the appeal, that’s it. You will either receive a lump sum settlement, or be put on claim, where plan benefits start as normal.

If they deny your appeal, then your only option at that point would be to file a lawsuit in federal court.

Should you hire an ERISA LTD Appeals Attorney?

This is a lot of information and a lot of dates to remember. You should seriously consider a free consultation with us, as you may not be familiar with some of the deadlines that may apply to your claim, and these deadlines are important in order for you to fight for, and receive the justice you deserve.

Use the form on our website or give us a call.

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