There’s a lot at stake. You are disabled and you can’t work. All you did was request the disability benefits you’re due under your employee benefits plan. But the insurance company has wrongfully denied your claim.
What do you do?
The attorneys at Marc Whitehead & Associates want you to succeed in appealing your group disability claim denial. We also know that you need to be well-prepared and informed when fighting an insurance company that simply does not want to pay your claim.
To be the best possible advocates for our clients, we offer the most current information on fighting denials of group disability claims, and what it takes to appeal a denial. We explain in plain English the ERISA laws that govern the whole business.
This is your place to find accurate information, get on solid footing and really understand what it takes to prevail in your ERISA appeal. We’re glad you’re hear and hope you find material that is helpful to you.
The information here is general and cannot pertain to any specific case. To request a free legal consultation with an experienced ERISA attorney, we are welcome your call: 800.562.9830.
We represent disability insurance cases on a contingency fee – this means that no retainer is required, and you pay no fees until we win.
ERISA and Its Cycle of Denial
Group disability plans are governed by federal law known as the Employee Retirement Income Security Act – a.k.a. ERISA. This has many negative effects on group long-term disability claims.
ERISA was originally enacted to protect employee pension benefits. It was never intended to be applied in the field of insurance. But over the years, lawmakers expanded ERISA law to regulate employee-sponsored long-term disability insurance plans.
ERISA preempts, or overrides, the consumer-protecting state laws governing insurance.
This means your group disability claim dispute has no state insurance law protections against fraudulent or unfair claims practices.
The result is tremendous unfairness to you and other employees seeking disability benefits.
ERISA strongly favors insurance companies, and it is very easy for claimants to make mistakes — both in the initial application and when appealing a group disability claim denial.
Insurance companies let ERISA protect them.
Insurers are well-aware that ERISA gives them the upper hand. They don’t want to pay on these claims. They take advantage of this cumbersome law by consistently denying valid claims and terminating existing benefits.
Our clients have dedicated ERISA attorneys protecting them.
From your position, it looks like insurers control everything. But they do not control everything. You need to level the playing field – and the best possible way to do that is to hire an experienced ERISA attorney to help you as soon as possible with your appeal.
When insurers don’t play fair, we can help in many ways. To your claim, our attorneys bring decades of experience representing disabled individuals who suffer all manner of medical impairments and work in every type of job classification.
Our strong ERISA background enables us to take the most efficient path to acquire the medical, vocational and financial evidence, reports and declarations to exhaustively support your case, and present it properly on appeal.
How Do You Appeal? Prepare, review, and then prepare some more.
Appeals require knowledge of how to use the insurer’s forms – with the foresight to supplement the appeal far beyond the insurance company’s paperwork. You develop a strategy based on the legal standard of review, and argue the insurer’s faulty decisions accordingly.
For the strongest appeal possible, a good ERISA disability lawyer will position your case for success with evidence that specifically explains why the insurer’s denial was wrong.
The remainder of this page talks about the steps to take when dealing with these insurance companies, and the type of information a proper ERISA disability appeal typically requires.
Insurance Companies We Fight
Marc Whitehead & Associates is a national law firm that has litigated against every major disability insurance carrier. Our attorneys deal with these companies on a daily basis, and are very familiar with each company’s claims handling practice.
Your insurance company has a team of professionals working to protect its interests, and you deserve the same advantage. We represent clients throughout the United States whose claims have been wrongly denied, unreasonably delayed or discontinued.
Disabling Conditions and Your Group Disability Claim
Watch out for insurance companies who resort to denial tactics targeting your medical impairment to keep from paying benefits.
They may allege you that you don’t have the objective medical evidence to prove that you suffer from a disabling condition. The reality is, not all impairments have objective evidence as proof of disability. This becomes critical to patients who suffer from symptoms that are difficult to diagnose.
Learn more about how your specific disabling condition relates to your ERISA disability claim and appeal.
We are prepared for the maneuvers insurance companies will take to misinterpret or undervalue our clients’ impairments. The court considers not only your diagnosis, but just as important the effect of your symptoms on your functional abilities.
Marc Whitehead & Associates can help you develop the necessary evidence to support your appeal regarding all types of physical injuries and diseases, and cognitive and mental disorders.
The ERISA Administrative Appeal
If your disability insurance company denies or terminates your group disability benefits, at this point the only means available to you to challenge the denial is to submit an administrative appeal to the insurer.
Here’s the ever-present reality check: With ERISA-based cases, because so many disability appeals are denied, you must assume the insurer wants to deny yours.
So we prepare our appeals to reach far beyond this administrative step. The appeal becomes your platform for potential litigation.
Every piece of information you need a judge to see in litigation must be part of the record during the appeal. Because once you file your appeal, your administrative record is closed.
This is your prelitigation strategy. A strong, comprehensive appeal makes it clear to the insurance company that
- you are disabled,
- the insurance company’s arguments are inadequate, and
- you are prepared to file suit against the insurance company with substantiated evidence that by denying benefits the company abused its discretion, and did not provide a full and fair review under ERISA.
You have a limited amount of time to put together and submit your appeal, and the clock starts ticking the day you receive your denial notice.
- You Have 180 Days to File Your Appeal: The law allows you 180 days from the date you receive notice of claim denial to submit your appeal to the insurance company.
- The Insurer Has 45 Days to Make a Decision: Once your appeal is filed, the insurer has 45 days to decide whether to approve or deny disability benefits. An insurer may ask for and receive an additional 30 days extension. The insurer must notify you of the request for an extension and explain why it is making the request.
180 days – 6 months – sounds like plenty of time. But truthfully you need to launch your appeal immediately. Six months is all the time you have to assemble, address and put together everything you can to prove you are disabled and that the insurance company failed to review as directed under ERISA.
ERISA Standards of Review (and What They Mean for Your Appeal)
Another unique feature of ERISA-based disability claims – as opposed to a non-ERISA case governed by state law – is that you don’t have the same burden of proof if you eventually sue the insurance company and take the case to court.
Why is this important at the Appeals stage? Because you want to take into account the standard of review your case will be subject to if you do go to court.
Remember your prelitigation strategy. Your appeal should make arguments appropriate to your claim’s standard of review. Coming up with these arguments after your appeals are exhausted is simply too late.
ERISA group disability claim denials are generally subject to one of two Standards of Review: arbitrary and capricious, or de novo.
- Abuse of Discretion Standard of Review (a.k.a. Arbitrary and Capricious)
Does your plan have “discretionary language” – language that gives the Plan Administrator the discretion to interpret the terms of the plan document? This type of wording gives the insurer authority to interpret the terms of the plan and to determine eligibility for benefits. If the Plan has this language, the standard of review will be the Abuse of Discretion standard.
Most ERISA claims are reviewed under this standard. Insurers are given broad discretion in court and their decisions will not be overruled unless the court finds they abused their discretion.
- De Novo Standard of Review: When discretionary authority (as above) is not granted through plan provisions, the de novo standard of review will apply. A court will independently review your claim and not defer to the insurance company’s decision. This is much better for claimants.
What standards of review will your claim be under? And how do you base your appeal on that standard of review?
What Goes In the Well-Planned, Fully-Developed Appeal?
The appeal letter should concisely state why you disagree with the insurance company’s denial, and what information you are including in your appeal that will change their minds. You will:
- Provide written rebuttal to each concern raised by the insurance company.
- Argue to reverse the denial by disclosing all deficiencies on the insurer’s part.
- Base your appeal on the standard of review a court will use when reviewing the claim.
- Make certain that once you submit the appeal, all of the information and evidence that you would ever need to litigate the claim is in the claim file.
It is your burden to gather, review and address:
- All Plan documents
- All concerns of the insurance company
- Treating doctors records and their letters of support containing their responses and counterarguments
- Relevant information about the insurer’s reviewing physicians
- Additional testing and evaluations: Medical, FCE, Vocational, and Neuropsychological
- Claimant’s affidavit – your personal statement, or declaration, of how your condition affects your everyday life. This is your opportunity to tell the court about who you are as a person, as well as give meaningful insights as to how your symptoms impact your ability to perform the duties of your occupation;
- Witness statements from co-workers, family, and friends
- Written support of your former employer if possible
- Social Security Disability decisions and other agencies’ awards of disability benefits
- Review and rebut any video or other surveillance
- Pertinent medical literature
How Our Attorneys Help With Your Group Disability Claim Denial
At Marc Whitehead & Associates, we understand the enormous challenges you face when trying to secure disability benefits. As ERISA lawyers we help people file, appeal and litigate group disability claims each and every day. We hope that you will call us with any questions you have about your claim, no matter what stage your claim is in.
Our firm has been very successful at winning disability claims at the administrative appeal level. We know the tactics insurance companies use to prevent having a denial remanded or overturned.
We work directly with your doctors, employers, peers, and family. We consult with our own authorities and experts to fully develop each appeal accordingly.
We want your benefits granted or quickly restored, without the need for a lengthy lawsuit.
A key factor in getting the best possible settlement is to let the insurance company know you are serious. Insurers must know that if they uphold the denial on appeal, you are represented by ERISA attorneys who are ready and waiting to file suit. We have worked hard to earn our reputation in the disability industry for fiercely defending our client’s rights.
We will be glad to review your claim and can help you wherever you live. Our legal consultation is free, and you will always gain meaningful information about your claim. To discuss your claim with us at any time, please call: 800.562.9830We also invite you to download our free ebook, Disability Insurance Policies: How to Unravel the Mystery and Prove Your claim, by attorney Marc Whitehead.