If your claim for long term disability benefits has been denied, you may be wondering what happens next. If your claim is under a group policy governed by the Employee Retirement Income Security Act (ERISA), you’ll need to file an administrative appeal of this denial to the insurance company before you go any further. The strength of your claim file will dictate what you can do next – once your appeal is denied, your claim file has closed, which means that any subsequent lawsuit can’t raise issues that aren’t contained within this file. Below are the six steps to appeal your disability insurance denial.
Step 1: Obtain a complete copy of the claim file from the disability company and review it in great detail.
At the appeal stage, your claim file is everything – if the symptoms and effects of your disability aren’t memorialized in your claim file, it’s as if it doesn’t exist. The first step to appealing the denial of your claim is to get a copy of the claim file from the disability insurance company. Under ERISA, the insurance company has 30 days from the denial letter to provide you with a copy of the claim file.
Once the disability insurance attorneys at Dell & Schaefer begin representing you, we’ll send a letter of representation out to the insurance company requesting a copy of the claim file and advising the insurer that all future communication with you must be made through your attorney. After we’ve received the claim file, we’ll quickly begin gathering medical evidence and doing all we can to bolster your claim on paper.
Step 2: Determine the additional medical and occupational evidence that supports the disability claim.
It may sound simple, but one of the keys to a successful disability appeal involves narrowing down the type of disability claim you have. Only then can you determine which medical and occupational evidence you’ll need in order to prove to the disability company that you’re entitled to long term disability benefits. For example, if you have chronic pain that prevents you from sleeping (and therefore working), what specific evidence in your claim file supports this? Do you have a doctor’s statement to connect the dots between your symptoms and your inability to work?
Step 3: Prepare a custom attending physician statement(s) for treating physician(s) and undergo any additional medical testing that will support the claim.
After reviewing the evidence you have (and the evidence you’ll need), it’s time to prepare your attending physician statement(s). This statement goes beyond the dry forms the insurance company requires you to fill out and is instead a narrative that details exactly how your disability affects you. The attending physician’s statement addresses factors like your medical condition, your occupational duties, and the language of the policy.
One of the biggest advantages of having legal representation during this process is the ability to create this attending physician’s statement yourself. The disability insurance attorneys at Dell & Schaefer can review your claim file and medical records and draft a letter that lays out all the medical documentation in a way that makes sense. At that point, all the treating physician needs to do is sign.
Step 4: You must provide as much occupational evidence as possible about the duties of your occupation. Don’t rely on your employer’s job description, as it’s inadequate.
To qualify for disability benefits, you’ll need to prove that your medical and/or mental health condition(s) prevent you from performing the substantial material duties of your own occupation. The more detail you can provide, the better – relying on your employer’s job description may not be enough, as it isn’t likely to cover everything you’re asked to do on a daily or weekly basis.
A vocational expert can be especially helpful during this step of the process – this is someone who can present a thorough, comprehensive picture of everything your job entails. Combining a vocational expert’s report with the attending physician’s statement and your medical records can create a claim that’s hard to deny on appeal.
Step 5: Identify claim handling actions in the claim file that represent an unreasonable review. DO NOT provide the insurance company with a road map for how to properly review your disability claim.
To prevail on appeal, you’ll need to show that the initial denial of your claim was unsupported by the record. This means not only building a robust file with medical and occupational support but also drafting the claim in a way that shows exactly what went wrong with the first review. However, one risk of this is that it will provide the insurance company with a roadmap of how to properly review your claim – with no guarantee that the outcome will be any different. Pointing out the problems in the prior review without tipping your hand to the insurance company can be a very fine line to walk.
Step 6: Draft your appeal in a very strategic manner that takes into consideration how a court will review the appeal if you lose.
Finally, you’ll want to draft your appeal in a way that sets you up well for future litigation if needed. An appeal should present your medical and vocational evidence in a way that allows the claim file to stand on its own. If the disability insurance company’s outside counsel sees that your claim is supported with strong medical evidence and a firm physician’s statement, they’re far more likely to settle than allow the case to go to court.
The more educated a disability claimant is about the appeal process, the better your odds of being approved for long term disability benefits. If you have any questions or want to get started with an experienced member of the legal team at Dell & Schaefer, just give us a call today to schedule your free consultation.