Private Disability and ERISA (Employer Provided) Disability Claims Appeals
If an insurance company denies your claim for long term disability benefits, you can file an appeal of the decision. This is your right. The insurer must allow you a full and fair review of a denied long term disability claim.
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What is an Appeal?
The appeal is a formal request for to reconsider an adverse decision made by the insurer. This may include a denial, reduction, or termination of benefits.
After you receive a denial letter, the long term disability appeal process depends upon the type of policy your have:
- You may have a group disability plan through your employer, which falls under federal ERISA regulation.
- You may have a private or individual disability insurance policy which you bought yourself. Private LTD claims are regulated by state insurance laws.
The laws governing each type of disability insurance are very different.
Long Term Disability Appeal Under ERISA
The Employee Retirement Income Security Act (ERISA) is a federal law that governs most group disability insurance benefits. This includes policies offered by employers, professional associations, or unions. ERISA law leans in favor of insurance companies, not the disabled. You must ask the same people who wrongly denied the benefits in the first place to reverse the decision.
Long term disability appeals for ERISA disability claims must follow an extensive administrative appeals process. You will have a deadline of 180 days for submitting your appeal.
The administrative appeals process is critical. The appeal becomes the framework for the successful outcome of your entire case. In the administrative appeal, the burden is on the insured to assemble and submit all medical and vocational evidence.
Every basis for the denial must be addressed in detail. You want to submit the best case you can to the insurer in hopes that it will reverse the denial.
You need to fully develop the record with evidence such as:
- Medical records from your treating doctors
- Medical expert opinions
- Vocational expert opinions
- Letters from employers and friends
- Medical evidence including literature and photographs
You must argue against the insurance company’s in-house medical reviews, as well as misuse or misrepresentation of the evidence by the insurer.
The insurance company decides whether to reverse its own decision. This is why many appeals do not result in claim approval. Insurers have nothing to lose by denying a claim. ERISA laws protect them from accountability that could result from a wrongful denial.
If the insurer denies the appeal at the administrative level, the next step is to file a lawsuit.
ERISA disability lawsuits are held in federal court before a judge, not a jury of your peers. Once a lawsuit is filed, it is most often the case that you cannot add any new evidence to the record. To avoid losing your appeal, it is strongly advised that you have skilled legal counsel to help you through the process.
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Individual Long Term Disability Appeal
Private long term disability policies are contracts between you and the insurance company. As such, these policies and claim denials are governed by state contract and bad faith law.
Unlike ERISA claims which require exhaustion of strict administrative appeals, private disability policies do not. If your claim is denied, you do have the right to appeal the private LTD claim denial to your insurer. This appeal is often nothing more than an internal review with the same insurance carrier that already denied the claim once.
When an acceptable settlement with an insurance company cannot be reached, bad faith insurance claim litigation becomes necessary. Bad faith occurs when an insurer unfairly or improperly withholds payment warranted under the policy. This includes thoroughly and promptly investigating all evidence in support of your claim.
In a lawsuit against the insurance company for denying private LTD benefits, you have certain rights not available under ERISA law:
- You are allowed a trial by jury.
- You may engage in evidence and discovery.
- Most states allow you to seek compensatory and punitive damages.
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The Importance of Attorney Help in Long Term Disability Appeals
Because you are in no condition to work, our firm will help you gather all needed evidence. We will:
- Prepare and file a proper and conclusive appeal
- Talk with your doctors obtain statements from witnesses
- Consult with qualified vocational experts
- Use the latest science and technology to investigate and build the details of your case
Long term disability appeals are complex. Your best chance of success is to have strong help from an experienced disability lawyer. We take care of all legal concerns that will affect the results in order to overturn your denied claim.
Our long-term disability lawyers are high rate of success in fighting denied ERISA and individual long term disability insurance claims.
We can help you fight against all of the major disability insurance companies in the United States. Call 800-562-9830 today to schedule a free consultation!
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