A disability insurance company’s decision to deny your claim can be traumatizing and infuriating. In short, the company that you placed your trust and financial well-being, as well as thousands of dollars in premium payments, is refusing to acknowledge and accept the severity of your impairing medical condition. However, it is important to know that a claims denial does not mean that you are not disabled and not entitled to benefits under your policy.
Insurance companies are for profit businesses. Their goal is to maximize profits by limiting liability. By denying your claim, your insurance provider deflects the adverse financial consequences that occur when liability is accepted. Disability insurance companies conduct actuarial studies and are well aware of the percentage of insureds that simply walk away from their claim upon receiving a denial letter. If your claim was denied, your insurance provider is hoping you choose to do the same.
As such, it is important that you act promptly to understand the basis of the insurance company’s denial. A disability insurance claim is governed by the terms, conditions, and limitations of the subject policy of insurance, as well as state insurance regulations. When a disability insurance provider denies a claim for disability insurance benefits, it is required to provide a reasonable explanation for its determination. This explanation should contain an overview of the contractual and factual basis relied upon by the insurance provider to deny liability. If your insurance company failed to provide a reasonable explanation for the claim denial, it may be in violation of your state insurance regulations and you should send a formal letter requesting the same.
The company’s position letter is important because many claim denials result from a claimant not providing documentation necessary to support the claim or the insurance company misapplying the terms of the disability insurance contract. At Seltzer & Associates, we start every review of our clients’ claim by analyzing their disability insurance policy and their denial letter. We scrutinize the information the insurance company relied upon to deny liability.
We establish a detailed plan with our clients and work to obtain the stronger evidence necessary to substantiate their claim. We also analyze and outline the deficiencies in the company’s claims determination. Upon completion of this review, we present our clients with multiple options to precede on their behalf, including submitting a voluntary appeal, engage in pre-suit mediation or litigation.
The Appeals Process
A voluntary appeal is often the most time- and cost-effective means to overturn your individual disability insurance claim denial. Unlike ERISA governed claims, which require the submission of an appeal, most individual disability insurance companies offer claimants a voluntary appeal rather than compelling litigation. Even if the denial letter does not advise of this option, our law firm will communicate directly with the insurance company to have the claim re-evaluated.
Individual disability claims are generally more complicated than claimants anticipate when they submit a claim. Claimants are easily overwhelmed by the disability insurance company’s requests for medical, financial, and occupational documentation. Claimants are unaware their disability insurance company employs a team of in-house medical, occupational, vocational and financial consultants to perform its claim reviews. These consultants are well trained and look to exploit any deficiency in the information provided by a claimant in the company’s best interest.
Unfortunately, most claimants lack the knowledge and resources to challenge the insurance company. At Seltzer & Associates, we work with our clients to obtain the necessary documentation to fully evaluate and most strongly substantiate their claim. During this process, we breakdown every aspect of the claim, including the medical, financial, and occupation information submitted to the company. We work to obtain all necessary medical documentation and, when necessary, we retain the experts necessary to best substantiate our clients claim.
Our legal team uses the appeal process to supplement the insurance company’s claim file and to put the disability insurance company on notice of the issues that will be litigated should it fail to reverse its position. We may outline the deficiencies in the company’s review, including contractual and legal issues relevant to each claim. Upon submission of the appeal, we engage in an open dialogue with the company to help expedite its review and obtain the most favorable result for our clients.
Mediation is another option we can pursue on our clients behalf to resolve a claim without filing a lawsuit. Typically, mediation is pursued when an appeal is not warranted or the company’s adverse decision has been upheld. Mediation consists of both parties presenting their positions before a mediator, a neutral third party. We carefully screen and select all mediators to ensure they have the knowledge and experience to provide a full and fair review of our client’s claim.
Often times, even after we have filed a lawsuit and are involved in litigation on a case, there will be an opportunity to enter mediation. This can come by agreement between all parties or at the direction of the presiding judge.
At mediation, we walk through the issues of our client’s claim with the goal of persuading the disability insurance company to reverse its position or to obtain a favorable resolution acceptable to our client prior to filing a lawsuit.