After a long term disability insurance claim is denied, the claimant’s first appeal is referred to an “administrative appeal.” This appeal is directly to the insurance carrier that denied the claim initially. Many claimants decide to appeal the insurance carrier’s denial on their own. Often, a claimant will write a one paragraph appeal stating “I appeal your decision. Please reconsider.” This approach rarely succeeds. An experienced attorney will perform many tasks on appeal, including writing an appeal letter that will address each of the carrier’s allegations, contacting and obtaining expert opinions, sending a claimant out for a functional capacity exam or other medical exam, obtaining updated medical records, and carefully going through the claims file to see if the insurance carrier followed the proper procedures in its handling of the claim. Over the next several blog posts I will discuss strategies that an experienced attorney may use to improve your chances of winning your claim. The most important is to get all your evidence in the administrative record before a final denial.
Loading the Administrative Record
During the administrative appeal process, medical records, medical literature and articles, doctor’s opinions, letters from friends or employers, photographs and all other types of evidence that document a claimant’s impairments can be submitted and made part of the “record.” Once all appeals that are allowed under the policy (usually two), the “record” is closed. There is case law that indicates that more material can be added to the record before a lawsuit is filed, but usually once all appeals are “exhausted,” the carrier will send any newly submitted evidence back. After a lawsuit is filed, nothing else can be added to the record. That is why it is so important to fully load the record during the appeals process. An experienced attorney will understand the importance and ensure that the record is loaded. Most major insurance carriers such as Unum, MetLife, Cigna and Aetna will not voluntarily allow a claimant to continue to submit evidence after the administrative record is closed.
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Mistakes That Even Lawyers Make
Lawyers who are not familiar with disability issues do not always understand what has to be proved. These lawyers may argue that because the claimant’s doctor or Social Security has found the claimant disabled, the insurance carrier “must” find the claimant disabled. Although these are factors to be considered and do support disability, these two factors alone will not prove disability to the insurance carrier. Some lawyers may not understand the difference between “own occ” and “any occ,” or the subtle differences in each carrier’s definition of “disabled.” Inexperienced lawyers may argue the medical diagnosis, which does nothing to help prove disability. But most damaging, inexperienced ERISA lawyers may make the mistake of not loading the administrative record as described above.
Always consult with an long term disability attorney experienced in disability and ERISA law. If you have questions, ask disability attorney, Marc Whitehead by visiting disabilitydenials.com or you can download Marc Whitehead’s free E-book, Disability Insurance Policies-How to Unravel the Mystery and Prove Your Claim.
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