Pitfalls Of The Disability Application Process – Part III – The Appeal

Employment / Personal Injury / Business

Despite your best efforts to reach an accommodation with your employer and submit an accurately worded and detailed long term disability benefits application with plenty of supporting documentation, the insurance company denied your claim.  If you have not talked to an attorney already, you need to do so now. 

While the insurance company internal appeal process is not complicated, anything you fail to submit during the appeal process cannot be introduced later in a court challenge.  I have seen applicants who have simply written a letter as their appeal restating their belief that they are entitled to benefits.  When the appeal is denied, the opportunity to produce additional medical records and letters of support from treating physicians is lost.  An attorney can help you see what you or the insurance company may have missed and advise you of your likelihood of success. 

Employer provided disability benefits are governed by a law called the Employee Retirement Income Security Act, or ERISA for short.  The law favors the insurance companies and challenging a denial of benefits is a difficult undertaking.  To prevail, all the insurance company needs to show is that it had a “reasonable basis” for denying the claim.  Often, this standard can be met by having the applicant’s file reviewed by an “independent” physician who renders an opinion that the applicant is capable of working.  The applicant has the burden of showing the insurance company’s decision was arbitrary.  Mounting a successful challenge requires a careful legal review of the insurance company’s entire claims file and the disability policy.

You are entitled to a copy of the disability policy and your insurance company’s file regarding your claim at any time.  You must send the insurance company a written request.  If they fail to send you the documents within thirty days, the insurance company can be fined $110/day.  Every evaluation of a claims denial must begin with a request for the file. 

An applicant has 180 days after the denial to submit any additional materials for the insurance company’s consideration.  The insurance company may take up to 90 days to make a decision.

disability application process

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