If your claim for long-term disability (LTD) insurance benefits has been denied, you shouldn't give up hope. Many ultimately successful LTD claims are turned down initially, and in fact, some insurance companies seem to deny almost all claims at the initial level, regardless of their merit. Thus, you shouldn't be surprised if you receive an initial denial, and neither should you be discouraged. With patience, persistence, and the help of an experienced attorney, you'll greatly increase your chances for a successful appeal.
Appealing a Denial: The First Steps
Get a copy of the policy. If you haven't already done so, obtain a copy of the LTD policy plan documents, including the summary plan description. You should be able to get this from your company's human resources department, if your employer provides group insurance, or directly from the insurer. Unfortunately, this task is not always as straightforward as it sounds. If your HR department or insurer fails to provide you with the plan documents, request them in writing from the plan administrator at the insurance company, who is required to provide them under a federal law known as ERISA. Remember that requests for plan documents, like all correspondence with your insurance company, should be sent via certified mail with return receipt requested.
Study the denial letter. Carefully review the denial letter sent by your insurance company, noting the reason(s) why your initial claim was rejected and any other information that might be needed to approve your claim. The denial letter should also explain how and when to file your appeal. Be sure to mark any deadlines on your calendar; missing a deadline is the quickest way to sink an otherwise worthy claim.
Consider hiring a lawyer. If you're planning to hire an attorney to handle your LTD case, you should do so as soon as possible. Most LTD claimants wait until receiving their denial letters to hire an attorney, but others work with a lawyer while filing their initial claim. Whenever you decide to hire a lawyer, look for an experienced attorney who specializes in ERISA law. He or she will work to put your case in the best light possible, often by obtaining additional medical evidence or soliciting opinions from your doctors or vocational experts. Moreover, many insurance companies and plan administrators, whether fair or not, seem to take a disability case more seriously when you are represented by counsel. Note that disability attorneys generally collect a fee only if you win your case.
How to "Stack the Record" With Favorable Evidence
It's essential to "stack the administrative record" with favorable evidence before exhausting your insurer's internal appeals process. Under ERISA law, federal courts usually refuse to consider any evidence that wasn't already presented to your insurance company or plan administrator in their internal appeals process.
Track down missing records. Unfortunately, it often happens that insurers and plan administrators fail to obtain all the medical records relevant to your claim, so be sure to find out which records were used to decide your case initially. If anything is missing, inform your claims representative and ask for confirmation as to when the records were requested and are received.
Find out if tests would help. Insurance companies commonly cite a lack of objective evidence as a basis for denying a claim. Contact your claims representative to ask if further objective testing, such as MRIs, x-rays, or blood tests, would help your case. In general, the more objective medical evidence you provide, the better your chances will be.
Request letters or expert testimony. There are also certain types of non-medical evidence that can bolster your case, including written observations from friends and family members concerning your limitations and testimony from a vocational expert (a person who specializes in knowing what types of jobs a worker with certain impairments can do). Vocational evidence can be particularly helpful if you have an "any occupation" LTD policy, which defines disability as the inability to engage in any job, not just your current one.
Keep in mind that the disability questionnaire and other paperwork used by your insurance company might be designed to elicit responses from you that could justify a denial. That is why it's so important to, first, answer all the questions from your carrier honestly and completely (using extra sheets if necessary) and, secondly, to supplement your file with other favorable evidence.
Ask your doctors for written opinions. Finally and most importantly, ask your treating physicians and specialists to provide written opinions as to what are your work-related limitations caused by your medical condition. If you're working with an attorney, he or she will be able to craft specific questions to your doctors based on the circumstances of your case. Treating doctors' opinions are critical when trying to convince an insurance company of your disability. Many doctors will charge a relatively small sum for completing LTD paperwork, but this is usually a worthy investment. If your physician is not willing to help with your case, consider switching doctors. A favorable doctor's opinion is that important.
If you've exhausted all of your administrative appeals (reviews within an insurance company) and your case still has not been approved, the final step for most claimants is to file a lawsuit in federal court. This is a confusing, time-consuming, and occasionally expensive process, and for those reasons it is one best handled by a long-term disability attorney.