Learn what to do and what needs to be included in a disability insurance appeal if your claim has been denied by Lincoln Financial.
GREGORY DELL: Hi, I am attorney Gregory Dell. I’m here today with Victor Pena. And Victor, let’s talk today about strategies and things that somebody who’s been denied a long-term disability appeal or claim, I should say, by Lincoln Financial.
Lincoln Financial – company been around for a long time. They’re one of the largest group disability insurers in the entire country. We know that they recently, in 2018, acquired the long-term disability division of Liberty Mutual, which was big.
So the two of them now are a top five largest disability group insurer in the country. But let’s get into person who’s watching this video recently had their claim denied by Lincoln Financial. They need to file an appeal. What is the most important thing that needs to be done in that appeal.
VICTOR PENA: Medical evidence, medical support – in an appeal, what your entire claim is based on. It’s what the insurance company looks at. They always fall back on those medical records to make sure that they’re consistent with what the claimant’s telling them – what they’re filling out on their claim forms. So as medical records are the most important thing.
GREGORY DELL: OK, so person has been denied already. They may or may not have requested their claim file. Obviously, the insurance company got the medical records.
Insurance companies, especially like Lincoln, often claim rep will be trying to say, hey, go ahead and submit an appeal. A new person is going to look at it, not me, because that’s the way it goes. Just get us some additional records and go ahead and send it in.
Now we know that’s basically a trap. That’s not the right way to do it because there’s so much more you can do to put in a great appeal. What is unique about what we do as lawyers helping a claimant with their appeal versus what a person would be able to do on their own?
VICTOR PENA: Well, one big problem with medical records in general is often, depending on the nature of the condition and depending on the doctor that you’re working with, doctors aren’t always the best at documenting medical records for purposes of a disability claim. So simply submitting medical records from a doctor isn’t always enough. Oftentimes, doctors have to be told how they have to document things, and certain insurance companies look for very specific things in those medical records.
So when we handle an appeal, we look for those deficiencies. We look at the medical records and how the doctors documented things over time, whether or not they actually reflect what the claimant – how they describe their condition to be affecting them on a daily basis. And wherever those deficiencies are, we work on kind of filling those gaps during the appeals process.
GREGORY DELL: So more specifically, I mean, the insurance companies like Lincoln has a two-page attending physician statement, which they request to be turned in. From us having handled thousands of disability appeals with every company, not just with Lincoln and what was Liberty Mutual, we have custom attending physician statements that are specific to a person’s medical condition and specific to the occupation, whether if it’s a definition of an occupation or any occupation. Is it a sedentary, a light duty, a medium duty? Is it a doctor? Is it an accountant? Is it a bookkeeper? Is it someone who has a desk job?
And based upon that, we consider every single one to be unique. So I find it impossible that the disability insurance company asks you for here’s our attending physician statement – the same one they use for every single claim. So there’s no way a claimant is going to be able to do that on their own versus what we customize for the doctors.
The other thing that we keep in mind is we know no matter what we send in is going to be looked at by their hired doctor, whether it’s in-house or outside. Very important that we’re considering how’s that other doctor that they’re going to hire going to look at what our doctor turned in. So we have to become like quasi doctors, which we’re not doctors. We’re never going to treat a claim, but we know enough to say, this is what the doctor is going to look for for medical support in the physician’s statement that we’re submitting.
And if we present it in the right manner, no reasonable doctor could disagree with that. So I think that’s huge in obtaining the medical records when trying to get physician support that a claim and just can’t go into the doctor and say, I need all of these things. And when we do that, the doctor is more responsive to the lawyer. Do you find they’re more responsive to you or to the claimant?
VICTOR PENA: Right, well, when you know what questions to ask, they tend to be more responsive. So oftentimes, a claimant will go in and try to describe to the doctor what you told them over the phone, and they don’t always relay that information exactly the same way. But yeah, generally, I find that the doctors that are supportive of the claimant tend to be pretty responsive, and they tend to work with lawyers pretty well.
GREGORY DELL: OK, so the other thing I want to talk about the importance of – look, it’s the inability to do your occupation or any gainful occupation. So in order to not do an occupation, you have to have some kind of restrictions or limitations. That’s one element of an appeal that you have to prove. The other element is, well, what is that occupation or what does any occupation mean? How do we present that to the insurance company in a light most favorable to our client?
VICTOR PENA: Well, one of the things that we also find insurance companies tend to do, they tend to simplify things. They oversimplify things, like your occupation, for example. They’ll just look at The Dictionary of Occupational Titles and the intended kind of group and occupation into either whatever physical characteristics if it’s sedentary or light duty, heavy duty occupation.
So often, they just focus on those physical requirements of an occupation. So when we do an appeal, we obviously break it down. We point out what those material and substantial duties actually are. And doing a vocational assessment is just that– presenting it in a way that paints a picture of what this claimant’s occupation actually consists of.
GREGORY DELL: And then we also have the resources throughout the whole country of what’s called a vocational consultant to work with an expert who will take all of the medical records, do a market labor analysis, look at jobs that are available, look at the skills required of a job, and write a pretty intensive report comparing the responsibilities for a particular job or any occupation and then comparing the restrictions and limitations that the doctor has proffered forward and the medical evidence that we’ve helped to gather and then render an opinion as to whether or not there’s any job that the claimant can do. So I think that’s unique because those reports cost a couple thousand dollars, and most claimants who are filing an appeal don’t want to put out money to hire, don’t even really know who to hire to submit one of these reports.
Since we handle these claims on a contingency fee basis, claimants don’t have to worry about putting out thousands of dollars we may spend on appeal because they won’t be responsible for that unless we win their appeal. So that’s a very big advantage for someone who’s considering to file an appeal. And they don’t get stuck at a disadvantage of not having that because the insurance companies have vocational experts. I mean, you’ve never looked at an appeal that wasn’t reviewed by their own in-house vocational consultant.
VICTOR PENA: Right and sometimes they make mistakes. We’ve seen cases where they misclassified. Even if you look at The Dictionary of Occupational Titles, and they’ve completely miscalculated the occupations. So it’s really important to look at and not ignore that aspect of the claim.
GREGORY DELL: Right, we’ve only talked about the medical and the occupational. There’s many other things that are super important in a Lincoln appeal. But what about this requirement from Lincoln for a second appeal? Do you have to do that?
VICTOR PENA: Yeah, so one of the things with Lincoln, there’s multiple carriers that offer two levels of appeal. Usually, the first one’s required. Second one is voluntary. So you can either go ahead and file a lawsuit and not be penalized for not submitting that second appeal.
But Lincoln, they have two levels, required levels of appeal. So you have to go through both appeals. If they deny the first, you have to submit the second appeal in order to preserve your right to any legal remedies.
GREGORY DELL: And those second appeals also have to be very strategically organized, and you really don’t know the strategy on that until you see how they reviewed the first appeal. And they’re very strategic, the second ones because maybe in the first one, they screwed something up so badly that you may be very limited in what you want to put in the second one because you don’t want to bring their attention to what they did wrong because of the fact of then when it gets to a lawsuit that the court will say, well, you told them what they did wrong. And now they reviewed it. And so you have to always do that balance because of the standard of review, which we’ve talked about in many other cases about the standard review in these ERISSA lawsuits.
So if you have a claim with Lincoln or what was formerly Liberty Mutual that’s been denied, we’re able to assist you anywhere in the country. We’ve handled thousands of these disability appeals, and we always offer you a free initial consultation. So we welcome you to give Victor call or any of our other disability lawyers, and we’ll let you know right away whether or not we can help you.