Have you received a denial letter from your long term disability insurance company? Now is not the time to fold in despair; it is time to take action! But first of all, what happened? Why did the insurance carrier deny your claim?
Remember that in group disability claims, your claim information is reviewed and evaluated by claims handlers who work for the insurance company. This reveals an inherent conflict of interest in most group disability cases.
While not all disability claim denials are wrongful, many of them are. Insurance companies resort to proven tactics and strategies by which they reject rightful claims. How can you fight back?
The video above explains why the denial letter is important:
- The letter summarizes the evidence the insurance company reviewed when making its decision.
- It shows who reviewed the evidence (was it an in-house nurse, a non-medical reviewer, or a physician hired as a consulting medical expert?)
- The denial letter should give the main reasons your claim was denied, and what medical evidence the insurance company needs to see to prove disability.
- Finally, the denial letter tells you that you have the right to appeal the decision, and gives you the time frames to follow.
The only path to overturning a denial and winning your rightful benefits is to appeal the denial with substantial evidence. A well-crafted appeal develops the entire claim file to include medical records, medical expert opinions, vocational expert opinions, letters from employers, coworkers and friends, medical literature, photographs and more. The goal is to create an airtight case.
The Denial Letter Is Just the Start. Now You Need your Claim File.
While the denial letter answers some key questions about why your claim was denied, it does not help you know the whole story, and what you really need to prove to win your claim. The whole story about your claim denial is in the insurance company’s administrative record.
This is your entire insurance claim file, containing all records submitted when you filed the initial disability claim, plus the insurer’s records of their review of your claim and their initial denial. Examples are:
- the insurer’s medical reviews with their exact reasons they do not consider you to be disabled
- results from a functional capacity evaluation or independent medical exam results
- video surveillance, social media, field interviews, phone calls and other investigative information they assembled on you in support of the denial
You must request the administrative record.
The insurance company is required by law to provide your claim file, but rarely with the company provided it without the insured claimant’s written request. So the first thing to do upon receiving the denial letter is to write to the insurance company ordering your copy of the administrative record.
With this information, you can argue every point the insurance company used to deny your claim, with essential facts and objective evidence in your favor that the insurer will have a hard time distorting or disputing.
Here’s why this is so important: You are also setting up your case for judicial review, if the insurer continues to deny your claim on appeal. It is highly likely they will, because in ERISA based cases, an insurance company has little to lose by continuing to deny.
Once all administrative appeals are exhausted, and the insurer still denies the claim, the case goes to trial before a judge (no jury) in federal ERISA court. At this time, the administrative record is closed, and you cannot add further evidence.
The judge will only review the evidence that is in the administrative record, to rule whether there was “substantial evidence” for the denial of the claim. The only issue is whether the denial can be justified based on the information that was available to the insurer.
The denial letter does not come close to supplying you, as claimant, the information you need to successfully appeal your case. You must have the administrative record as well. Then you can develop your appeal and load the record with substantive medical and vocational evidence in support of your claim.
Get the Help You Need: Ask for a Free Case Evaluation
Claimants are most often successful when they have strong representation from an experienced disability lawyer.
At Marc Whitehead & Associates, we take care of everything. The moment you become our client, we set out to remove your burden.
Our attorneys can assist with every step, beginning with ordering the administrative record. We will work with your doctors, and medical and vocational experts to substantiate your disabling condition and to specifically rebut any issues undermining your claim.
We are familiar with the claims handling practices of all major insurance companies, and we protect our clients from biased claim administration.
Insurance companies frequently deny meritorious disability claims and get away with it. This is by virtue of the ERISA laws that make it easy for insurers to reject disability claims through deceptive practices.