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The Appeal Process for Long-Term Disability Denial
In case you, or a person close to you, have been denied long-term disability (LTD) benefits, it is important not to lose hope. It’s crucial to understand that many LTD denials may not be justified. In the journey through the long-term disability appeal process, a pivotal question arises: Has UNUM denied your long-term disability claim?
Every LTD policy provides the opportunity for at least one or even two administrative appeals. Utilizing this appeal process is usually essential in order to rectify an unjust denial of LTD benefits.
The Influence of ERISA on Your Appeal
If your LTD plan has been provided by your employer as a group plan, it is highly probable that it falls under the regulations of the Employment Retirement Income Security Act (ERISA), a federal law.
ERISA mandates that all your appeals must be exhausted before you can file a lawsuit against the insurance company. In simpler terms, you are required to first challenge your denial using the insurance company’s appeals process. You can only proceed with a lawsuit in a federal court if your denial is confirmed upon appeal.
If your LTD plan is not regulated by ERISA, you might have the option to directly file a lawsuit instead of an administrative appeal. However, this depends on the terms stated within your policy and the applicable laws. A seasoned LTD attorney is well-equipped to review your policy and provide the necessary advice on future actions.
How ERISA Favors Insurance Companies
Despite ERISA’s intention of safeguarding employees, it includes certain regulations that can work against claimants and in favor of insurance companies.
- Primarily, ERISA cases usually rely on the “abuse of discretion standard” to review denials. This standard tends to favor insurance companies, allowing their decisions to stand even if found to be incorrect, provided the process they used to arrive at the decision was deemed “reasonable”;
- Secondly, ERISA stipulates that you must provide all pertinent information to validate your claim during your appeal. ERISA prohibits the submission of additional evidence later if it wasn’t included in the original appeal. Hence, if you miss out on any crucial evidence, you won’t have an opportunity to rectify this later;
- Thirdly, ERISA permits insurance companies to set strict deadlines for filing your appeal. This deadline is usually highlighted in your denial letter. Most policies allow a 180-day window to file an appeal, but this time frame may vary based on the individual policy. Do not miss these deadlines as they can lead to the expiration of your right to appeal.
Guidelines for Submitting an ERISA LTD Denial Appeal
- Review the Denial Letter: Initially, it’s imperative to thoroughly understand the reasons behind the denial of your LTD claim outlined in your denial letter. This knowledge will allow you to identify what additional information you need to include in your appeal;
- Request Your LTD Claim File: After receiving your denial letter, you should request a copy of your claim file from your LTD insurance company. As per ERISA, the company is obliged to provide a free copy. The claim files are often vast and could run into thousands of pages. Carefully scrutinizing these documents will further elucidate the reasons behind your claim denial and guide you on what additional documentation might be needed;
- Include all Relevant Information in the Appeal: ERISA does not permit any additional information to be submitted after the administrative appeal. Hence, it’s crucial to include any and all information you can gather to strengthen your claim during your appeal process. This information can include inputs from your doctor, vocational expert, reports from friends and family, or any other relevant data. Failure to submit all necessary information might lead to being barred from submitting any further information later.
Understanding the Role of a Long-Term Disability Lawyer
If you have been denied LTD benefits, consulting with an ERISA-trained LTD attorney is of the essence. Given the complicated legal nature of ERISA claims and the limited number of attorneys handling these claims, it’s not advisable to handle these cases independently. Even federal courts concur that claimants, due to the complexities involved, should not navigate ERISA claims without legal assistance. ERISA’s rules lean more towards safeguarding insurance companies’ decisions than helping claimants, and the risk of potentially damaging your claim through an inadvertent mistake is high.
How to Choose the Right Long-Term Disability Attorney
Finding a skilled and experienced LTD attorney is crucial for your appeal process. Here are some tips for finding the right attorney:
- Ensure the attorney specializes in ERISA law and has handled LTD claims;
- Check their track record and client testimonials;
- Make sure they clearly explain the process and are transparent about the fees;
- The attorney should be able to commit enough time and resources to your case.
The Importance of Timely Action
It is important to act quickly after receiving your denial letter. Given the strict timeline for appeals, you should immediately:
- Seek legal advice to understand your best course of action;
- Inform yourself about the appeal process such as reading guidebooks about how to file an appeal;
- Schedule a consultation with a disability insurance lawyer and start preparing for the appeal.
Conclusion
While the process of appealing a Long Term Disability denial can seem intimidating and complex, understanding the guidelines and navigating them effectively is crucial. The role of an experienced attorney in this process cannot be overstated. They can provide guidance, support, and expertise, significantly increasing your chances of a successful appeal. Remember, acting swiftly and decisively can make all the difference when it comes to reinstating your long-term disability benefits.
