So, your long-term disability, health, or life insurance claim has been denied—and now you’re looking for answers. Maybe your insurer decided you weren’t sufficiently ill to stop working, or declared the treatment you submitted was not medically necessary. Or perhaps they marked your life claim as invalid because the application for coverage was not completed properly. We see all of these dubious reasons for denial of claims on a regular basis.
Your denial letter doesn’t have to be an ending, though. In fact, your insurance company is banking on the fact that you’ll accept its refusal lying down.
Most policyholders don’t have the legal knowledge or resources to understand the importance of the appeals process—or the procedural landmines involved in the process. Insurance companies use this lack of knowledge to avoid paying valid claims, simply denying claims and hoping their insureds just go away. However, savvy claimants can circumnavigate this roadblock with the assistance of experienced ERISA counsel.
Your denial letter will likely list the relevant filing deadlines and guidelines for the company’s process. But before crafting your appeal, know that you’re kicking off a complicated and multi-faceted legal process. Claimants that consult an attorney during the initial appeals process are much more likely to reach a positive outcome.
Ready to make your case? Let’s examine why having an attorney who knows ERISA well is the right choice when filing your ERISA long-term disability insurance appeal.
Denied? The Administrative Appeal Procedure Explained
The administrative appeals procedure is governed by a federal law enacted in 1974 known as the Employee Retirement Income Security Act (ERISA). The congressional intent in enacting the law was to ensure that employees receive their promised benefits by requiring insurance companies to offer a full and fair review process before denying a claim.
ERISA dictates that claimants must follow their insurer’s appeals process before they can file a lawsuit for wrongful denial of insurance claims. So, this means your first step in resolving the matter is initiating the appeals process.
Your denial letter should state the reason your insurance claim was denied, as this information forms the basis for your appeal. You can then gather evidence as to why the specific reason for denial is unsupported. Your appeal must also align with your policy’s terms and conditions, which you should contact your plan administrator to receive.
This process might seem straightforward—but the reality is that you’ll be wading through endless pages of specific and complex legalese.
Your rightful appeal can easily be denied by a slight procedural misstep on your part. For example, your denial letter might tell you that you “may” file an appeal if you don’t agree with the denial. But the insurance company will leave out a crucial detail: that if you don’t appeal, your right to sue them is forever waived.
As with much legislation originally intended for consumer protection purposes, ERISA’s intricacies are unfortunately often weaponized for insurance companies’ benefit, not insureds. That’s why you’ll want to arm yourself with a partner who understands the legislation thoroughly and speak with an ERISA attorney about your appeal. They’ll be able to review your denial letter and policy information to represent you in crafting a successful appeal—and file a lawsuit for you should you need to proceed further.
The Crucial Elements of a Comprehensive Appeal
It’s critical to note that under ERISA, if you exhaust the appeals process and file a federal lawsuit, you cannot later submit evidence that wasn’t given to the insurance company in your appeal. Should the case proceed to litigation, the judge can only consider documents submitted during your initial administrative reviews. This means that it’s absolutely essential to build an appeal with comprehensive evidence and information.
A well-crafted appeal is the most effective way of avoiding litigation in the first place—by putting the insurance company on notice that your claim cannot be rationally denied.
You’ll want to start by requesting your administrative record (also known as a claim file) and filling in any missing documentation, including any additional supporting evidence. If you are appealing a long-term disability or health claim denial, by the time you're ready to finalize your appeal submission to the insurance company, your appeal should include:
- Medical evidence such as comprehensive records, detailed diagnostic reports, test results, doctor's letters, and opinions from vocational specialists regarding your inability to work if the claim is for long-term disability insurance benefits.
- Well-structured statements from friends and family testifying to the reality of your disability.
- Your own factual statement regarding your condition. Make sure it points to specific policy terms and conditions that support your long-term disability insurance claim or are contrary to its denial.
- A statement from your doctor describing your condition in detail, as well as their contact information.
The Role of Legal Counsel Before Filing an Appeal for Long-Term Disability Insurance
The unfortunate reality is that your insurer's financial interest does not align with your own. In this sense, the complexity of the appeals process works to protect the interests of insurance companies by putting claimants through a process that’s out of most people’s depth—except for those with an experienced ERISA lawyer.
As you know, the insurance company is ready to deny a claim for any qualifiable reason—and has a team of lawyers at the ready to support their reasons for denying your claims. So to properly respond to their denial, you’ll want someone equally as knowledgeable to fight for you.
Your ERISA lawyer will walk you through the process, focusing on potential legal arguments, how to craft them, and what evidence you need to gather. The goal: crafting an appeal so strong that continuing to denying your claim will only make the insurance company look foolish or overly financially self-interested before a court.
Affording an ERISA Lawyer: Understanding Contingency Fees
Clearly, most claimants would prefer that an ERISA attorney handle their long-term disability insurance claim appeal. However, many let concerns regarding how to pay an attorney stop them from even looking for help.
The vast majority of experienced ERISA lawyers use a contingency fee structure, which means you only pay if your lawyer is successful in obtaining benefits for you. Your attorney receives a predetermined percentage of your winnings if your appeal is successful; thus, in the unlikely event that your case does not prevail, you need not pay anything at all.
So you can obtain professional help—even if you don’t have the funds to cover the hourly costs. In fact, one could argue that the bigger risk is in not hiring an attorney.
Navigating the ERISA Long-Term Disability Appeal Journey
Once again, just because your claim was denied doesn’t mean you’re at the end of the road. The denial letter you received is simply the start of a lengthy appeals process—which is your chance to prove that your disability claim is valid.
Navigating the complexity of ERISA regulations, your insurance policy, and your specific case factors all at once can be overwhelming. Yet it may be critical to your long-term health and finances that you win this case—even though you’re up against your insurer’s extensive resources.
Of course, once you decide to get an attorney, your next challenge is deciding which attorney to hire. You need an ERISA expert in your corner—like the team at Kantor & Kantor LLP. The attorneys at Kantor & Kantor have extensive experience in long-term disability, health, and life insurance cases and will craft the best possible appeal for your case.
Before hiring any attorney, it’s important you have a thorough understanding of the pros and cons of different practices—and which makes the most sense for your case. Get in touch to find out more.
Reach out to set up a consultation with an ERISA attorney at Kantor & Kantor today.
