Texas long term disability lawyer Marc Whitehead, Board Certified Long Term Disability Attorney, discusses how to understand your denial letter.
Long Term Disability Insurance companies are notorious for denying legitimate claims based on obscured disability definitions contained in the policy. There is no one legal definition of disability. Every insurance company, the Social Security Administration, and the Veterans Administration all have different definitions.
After a Long Term Disability Insurance Claim is filed the insurance carrier will either grant the claim or deny claim. If the claim is granted the insurance company will begin to pay monthly benefits. If the claim is denied the claimant will receive a denial letter. This letter is very important because it will list the evidence the insurance company reviewed when making it’s decision. Who reviewed the evidence- for example an in house nurse, case manager or even a doctor hired as a consultant or non- medical reviewers. Most major insurance carriers such as UNUM, Cigna, MetLife, and Aetna follow this procedure.
The denial letter should state the reasons this claim was denied and what medical evidence the carrier needs to prove disability. The denial letter will also give important information for an appeal including, when and where an appeal must be received, the time limits for filing an appeal, and how the administrative appeal should be structured.
What are the time limits for filing your administrative appeal? The denial letter will give you the time limits for filing the appeal. If the policy is governed by ERISA or the Employee Retirement Income Security Appeals Act, the appeals deadline is 180 days. Most non-ERISA policies also give the claimant 180 days to appeal but it is very important to read the denial letter carefully so no deadlines are missed.
If an appeals deadline is missed the claimant will be unable to appeal further or file a lawsuit in Federal court to enforce their rights. If the claimant doesn’t exhaust or use all of the appeal available the claimant will not be allowed to file a lawsuit.
As I just stated, Long Term Disability Insurance claims are usually governed under Federal ERISA regulations. If a claimant goes through the Administrative appeals process and is denied their disability benefits their only remedy is to file a civil lawsuit to enforce their rights under the policy.
This leads to several important questions.
The first questions is- Who can sue?
Any plan beneficiary or participant may bring suit to enforce their rights under the plan or policy. This generally means the disabled individual, but in some cases it could mean their spouse or an estate. Typically in disability claims the suit will be brought against the plan or the plans fiduciary.
The second question- Who do you sue?
Typically in a disability plan the suit will be brought against the plan or the plan fiduciaries, often called the plan administrator. Frequently the plan administrator is the under writing insurance company. That’s the reason we generally refer to the insurance company throughout our eBook when we are speaking about the plan.
Occasionally, but not often, the proper defendant is the claimants employer. The test is who had authority under the plan to grant or deny a disability claim. Most major insurance carriers such as UNUM, Metlife, Cigna and Aetna follow this structure.
ERISA based Federal Lawsuits are complicated and can’t be filed in your local county of in small claims court.
Always consult with an experienced ERISA attorney before pursuing any legal action.
