If an insurance company denies your claim for long-term disability benefits, you can appeal your long-term disability insurance denial. This is your right, and the insurer must allow you recourse to a full and fair review of a denied claim. This is true whether you have a private disability policy or an employer provided ERISA governed policy.
What is an Appeal?
The appeal is a formal request for a re-consideration of an unfavorable decision made by the insurer, such as a denial, reduction, or termination of benefits.
The process involved in a long term disability appeal depends upon the type of LTD policy your claim is under:
- You may have an employer-funded group disability plan, 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 regulating each type of disability insurance are very different.
ERISA—the Employee Retirement Income Security Act—is a federal law that regulates most group disability insurance benefits provided by employers, professional associations, or unions. ERISA long term disability appeals must follow an extensive administrative appeals procedure. You will have a deadline of 180 days in which to file your initial appeal.
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The administrative appeals process is critical.
The appeal becomes the framework for the successful outcome of your entire case. You need to be vigilant and fully develop the record with pertinent evidence, such as medical records, medical expert opinions, vocational expert opinions, letters from employers and friends, medical literature and photographs. You need to effectively argue against the insurance company’s in-house medical reviews, and any misuse or misrepresentation of the evidence by the insurer.
If your claim is not approved once the appeals process is exhausted, the next step is to file a lawsuit. ERISA disability lawsuits are held in federal court before a judge, and not before 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. That is why, to avoid losing your appeal, it is strongly advised that skilled legal counsel represents you throughout the appeals process.
Individual or Non-ERISA Long Term Disability Appeals are different.
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-based 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. Be aware, this appeal is often nothing more than an internal review with the same insurance carrier that denied the claim in the first place.
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 the denial of private LTD benefits, you have certain rights that are not available under ERISA law: you are allowed a trial by jury, you may engage in evidence and discovery, and most states allow you to seek compensatory and punitive damages.
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It is Important to have a qualified Attorney Represent you in your Long Term Disability insurance Appeal.
Because you are in no condition to work, our firm will help you gather all necessary documentation, prepare and file a proper and conclusive appeal, talk with your doctors, obtain statements from witnesses, consult with qualified vocational experts, and use the latest science and technology to investigate and build the details of your case.
Long term disability appeals are complicated. Claimants are most often successful when they have strong representation from an experienced long term disability lawyer. Marc Whitehead & Associates is a national disability law firm representing disabled individuals in all 50 states.
If you have questions about your disability claim, visit our website or download a copy of our free E-book today!
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