When you can't work because of a serious illness or injury, long-term disability (LTD) insurance is there to protect your income. LTD insurance pays monthly benefits directly to you when a covered disability keeps you from earning a paycheck.
Unfortunately, many LTD claims are initially denied, only to be approved on appeal. In fact, some insurance companies seem to deny almost all claims at first, regardless of their merit. So if your claim for long-term disability insurance benefits has been denied, you shouldn't give up hope.
You can generally appeal an LTD denial. With patience, persistence, and preparation (and sometimes help from an experienced attorney), you'll greatly increase your chances for a successful appeal. Here's what you need to know if your long-term disability claim was denied and how to appeal an insurance denial.
The first step in preparing your long-term disability appeal is understanding why your LTD claim was denied. There are many reasons you might receive a long-term disability denial, including:
Understanding why your long-term disability claim was denied is the first step in appealing the insurance denial.
If you haven't already done so, get a copy of your 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 isn't always as straightforward as it sounds. If your HR department or insurer fails to provide you with the plan documents, request them in writing (via certified mail with return receipt) from the plan administrator at the insurance company. The plan administrator is required to provide them under a federal law known as the Employee Retirement Income Security Act (ERISA).
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. Many LTD insurance denials happen because of technical issues, rather than the merit of the claim. Make note of the following:
The denial letter should also explain how and when to file your appeal. Be sure to mark any deadlines on your calendar, as missing a deadline is the quickest way to sink an otherwise worthy claim.
Once you understand why the insurance company denied your long-term disability claim and how your insurance company's appeals process works, you can begin building your case.
If your LTD insurance denial was due to a technical issue, like a missing form, get the form completed so you can include it with your appeal. Make sure your insurance company isn't missing any of your medical evidence.
Unfortunately, it's not uncommon for insurance companies and plan administrators to fail to obtain all the medical records relevant to your LTD insurance claim. Find out which records the insurance company used to decide your case initially. If anything is missing, inform your claims representative.
Ask for confirmation of when your medical records were requested and received. And gather any missing records to include in your appeal.
If you're planning to hire an attorney to handle your LTD case, you should do so as soon as possible. Most people applying for long-term disability wait until receiving their denial letters to hire an attorney. But others opt to work with a lawyer while filing their initial claim.
Your attorney 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. And many insurance companies and plan administrators, whether fair or not, seem to take a disability case more seriously when you're represented by an attorney.
Whenever you decide to hire a lawyer, look for an experienced attorney who specializes in ERISA law. Note that disability lawyers generally collect attorneys' fees only if you win your case.
It's essential to "stack the administrative record" with favorable evidence before completing your LTD insurance company'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.
And keep in mind that the disability questionnaire and other paperwork used by your insurance company might be designed to get you to respond in ways that could justify a denial. That's why it's so important to answer all the questions from your carrier honestly and completely (using extra sheets if necessary) and to supplement your file with other favorable evidence.
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 would help your case. You might strengthen your claim by getting additional:
In general, the more objective medical evidence you provide, the better your chances will be of getting your insurance denial overturned.
Certain types of non-medical evidence can bolster your case for long-term disability benefits, including:
Evidence from a vocational expert can be particularly helpful if you have an "any occupation" long-term disability policy, which defines disability as the inability to engage in any job, not just your current one.
Finally and most importantly, ask your treating physicians and specialists to provide written opinions about the work-related limitations your medical condition causes you. Your attorney, if you have one, will be able to craft specific questions to your doctors based on the circumstances of your case.
The opinions of the doctors treating you are critical when you're trying to convince an insurance company of your disability. Many doctors will charge a relatively small fee for completing LTD paperwork, but this is usually a worthy investment. If your physician isn't willing to help with your case, and you believe your condition is severe, consider switching doctors. A favorable doctor's opinion is that important.
If you've exhausted all your administrative appeals (reviews within an insurance company) and your LTD insurance claim still hasn't been approved, you can file a lawsuit in federal court. Going to court can be a confusing, time-consuming, and occasionally expensive process. For those reasons, you should consider hiring a long-term disability attorney.
(Find a lawyer specializing in long-term disability claims in your state.)