If you were wrongly denied benefits under an Anthem Life Disability claim, as LTD insurance lawyers we can help you take legal action to get the benefits you need and deserve.
Anthem Life Insurance Company is a subsidiary of Anthem Inc., a billion dollar health care and insurance company. Anthem Inc. merged with WellPoint Health Networks, Inc. According to the AMA, Anthem Inc. is the nation’s largest health insurer in many local markets.
Anthem Life is in the Blue Cross and Blue Shield network of companies. In the disability insurance market, Anthem Life offers
- Group short-term disability insurance
- Group long term disability insurance
- Voluntary short and long term disability (in some regions)
All of Anthem Life’s disability plans are group plans that are employer-sponsored, and therefore governed by federal ERISA law.
ERISA law leans in favor of insurance companies, not the disabled claimant. If Anthem Life unfairly denies your claim, you must go back to Anthem Life to ask them to change their decision.
If your disability insurance claim was denied by Anthem, or if benefits have been terminated, you should consult with a qualified lawyer straight away. You have a short amount of time to appeal a claim denial, and will need an experienced ERISA claim attorney to prepare a rock solid appeal.
Examples of Anthem Life Disability Claim Review and Denial
Like many insurance companies, is not uncommon for Anthem to take maneuvers to avoid paying claims. Here are a few examples.
Own Occupation Changes to Any Occupation:
As with many group disability insurance plans, Anthem Life’s policies are written with a 24 month “own occupation” definition of disability. Once 24 months are up (generally as a short term disability claim) the policy definition changes to “any occupation.” If you are awarded the maximum amount of short term disability benefits (you were disabled from performing your “own occupation”), Anthem ends benefits by denying long term disability benefits, because your condition is not severe enough to keep you from performing any occupation.
This strategy give insurers a way to allege that the medical or vocational evidence submitted in your claim does not support that your impairment is severe enough to justify that you are totally disabled from working at any occupation in the national economy – a claim that is much harder for you to prove.
Third Party Medical Reviews to Override Your Treating Physician’s Opinion
Another course of action routinely taken by Anthem Life is to use third party independent medical reviews of your initial claim or during the appeal process. These third party reviewers frequently conclude or allege that
- there is not enough objective or clinical evidence to support your disability,
- you do not meet the plan’s definition of disability (i.e., you can still do the material and substantial duties of your regular occupation, or
- or simply ignore your treating physician’s medical opinions or only do a limited “paper review” of your disability – hence deciding you are not disabled.
Without just cause, these actions become unfair ways to deny an initial application or an administrative appeal of the denied Anthem Life disability claim.
Abuse of Discretion by Anthem Life
In addition to other judicial decisions, the court has ruled against Anthem Life for denying LTD benefits on such grounds, which – when shown to be unreasonable – come under the standard of the “abuse of discretion.” This means the insurer, by denying a claim, has acted in its own self-interest.
However, it takes a well-developed administrative appeal to prevail in federal court, and for judicial review to find in your favor.
What to Do if Anthem Denies Your Claim
Your first task after you receive a notice that Anthem has denied your disability claim is to determine the reason for the denial. Anthem will send you a letter that includes the reasons for its denial decision. Some of the more common reasons include :
- Your disability does not preclude you from any occupation. Anthem may, for example, agree to pay limited short-term disability benefits if you are unable to perform the tasks of your current occupation. After short-term benefits expire, Anthem may take a position that you can switch to a different occupation that is not affected by your disability.
- Anthem has concluded from a third-party medical review that medical evidence does not support your disability claim.
- Anthem might also conclude from the available medical evidence that your specific disability does not meet the definition of “disability” in your insurance contract.
- Anthem might simply disagree with a physician’s assessment of your condition and respond by saying that you are not disabled.
Understanding Anthem’s rationale for denying your claim is critical because you need to respond to the specific reasons for the denial when you appeal Anthem’s decision. If you only ask Anthem to reconsider its denial or you file an appeal without pointing out why Anthem’s decision was incorrect, your appeal will not be successful.
Like all disability insurers, Anthem often uses technical, industry-specific terminology in its denial notices that can be confusing to a layperson. Even if you think you comprehend the rationale stated in Anthem’s denial notice, you should consult with an experienced Anthem disability denial lawyer to verify your comprehension.
That lawyer can also help you manage your next task, which is to prepare and file the strongest appeal possible to Anthem’s denial of your claim. Anthem’s internal claims review team reviews thousands of claims and appeals every year. You can substantially approve the odds of a successful appeal when you hire a claims denial attorney whose knowledge and skills match the experience of Anthem’s team.
The appeal itself will first be processed through Anthem’s administrative channels. If Anthem continues to deny your claim, you may then have an option to pursue your claim through a state or federal lawsuit. Your disability lawyer will advise you through every step of this process, which might require:
- Further medical tests and examinations
- A thorough review of all paperwork that supported your original claim and preparation of new documents for the appeal
- Preparation of specific fact-based and legal arguments to rebut Anthem’s denial of your disability claim
- Monitoring deadlines and time limits to submit forms, pleadings, and evidence
- Filing and briefing a lawsuit to protect your rights under your Anthem disability insurance contract
When you retain an Anthem disability denial attorney to help you with this process, your attorney will make sure that your claim gets the individual attention it deserves and that it is not just another faceless claim that winds slowly through Anthem’s claim review department.
Ask Our Anthem Life Disability Claim Lawyers about Your Options
If you need help in preparing a legally sound disability appeal — or if you just have questions about your claim — please contact our law firm for an informative and free case evaluation with one of our long-term disability lawyers.