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It takes knowledge, perseverance, and strategic planning to succeed with a high-stakes appeal when an insurance company denies your claim for benefits under your disability insurance policy. There is considerable information available about appealing Social Security Disability Insurance denials, but the process and the laws involved are entirely different when you are dealing with private disability insurance.

Professionals who have invested their lives in developing their expertise and skill rely on private disability insurance to protect them if an illness or injury prevents them from practicing their profession. But far too often, when the time comes to file a claim, policyholders in good standing find that their claims are denied and they are left struggling to understand their rights and how to enforce them.

At Seltzer & Associates, we founded our firm decades ago to help physicians, accountants, attorneys, executives, and other professionals get the benefits they deserve under their private disability policies. Professionals are more likely than others to have their claims denied for a number of reasons, and one reason is that these claims involve payouts of significant amounts, frequently amounting to hundreds of thousands of dollars or more. When dealing with these high-stakes claims, insurance companies devote extra resources to negativity at every step in the process.

We know how to overcome their tactics, and we regularly help professionals successfully appeal denials of claims for a wide range of physical and mental conditions. Here we explain the process of winning a high-stakes disability insurance appeal, including:

• Why professionals so frequently have their disability claims denied
• What to expect during the appeal process
• How an appeal differs when an ERISA policy is involved
• When litigation becomes necessary
• Strategies for success

A denial is disappointing but not unexpected. It is what you do next that determines whether you will receive the resources you deserve from your policy.

Why are Disability Insurance Claims Denied?

Insurance companies are actively looking for reasons to deny disability insurance claims, and they can often find reasons within the policy terms or in information they gather from independent medical exams and surveillance of claimants. But the most common reason for denials is lack of convincing medical evidence. Understanding why a claim has been denied is one of the most critical steps in a successful appeal process.

Why is the Medical Evidence You Submitted Not Enough to Satisfy the Insurance Company?

Highly intelligent people easily follow logical trains of thought, but when dealing with insurance companies, it is necessary to document every aspect of a situation, even if it seems obvious. You need to clearly explain what your disabling condition is, describe all the symptoms, explain how each symptom affects your ability to perform specific functions, and why each of these functions is critical to the performance of your job. Each missing link in the chain of evidence and reasoning will be used as grounds to deny your claim.

Some reasons why your medical evidence might be deemed insufficient include:

• Lack of objective testing
• Gaps in documentation from physicians
• Treatment records that are incomplete

Perhaps the most important piece of medical evidence is the physician statement. Your treating physician should submit an extremely detailed statement describing your diagnosis, your treatment plan, and the limitations caused by the condition and treatment. 

However, the insurance companies often mislead claimants into thinking that all they need is a sentence or two mentioning the disability. They may provide a form with just a couple of lines for a response. But in our experience, we’ve seen that it is necessary to attach a separate, lengthy, detailed statement to satisfy the insurance company’s requirements.

What Policy Terms Could Provide Grounds for a Denial of Benefits Under My Disability Insurance Policy?

Your eligibility for disability benefits is determined by compliance with terms in your policy because it functions as a contract. You must convince the insurance company that your condition meets the definition of disability as set forth in your policy—and there can be a wide degree of variation between the definitions in different policies.

Many professionals seek coverage that protects them if they become unable to practice their own occupation specifically. However, most policies are written so that disability is defined as the inability to practice any occupation at all. Insurance companies will insist that even if a financial executive suffers a cognitive impairment that prevents them from concentrating on numerical analysis, that executive can still work as a greeter at a big-box store, so there is no qualifying disability.

Even when a policy clearly specifies that the policyholder qualifies for benefits when a condition prevents them from practicing their specific profession, the insurance company may wrongfully claim that the professional retains enough abilities to continue to practice. For instance, if a dentist suffers from pain or paralysis that makes it impossible to perform procedures and examinations on patients, the insurance company might argue that the part of the dentist’s job includes evaluating information on patient X-rays, and since the dentist is still able to look at X-rays, that dentist is still able to practice the profession.

It is important to understand what the terms of your policy specify, but it is also vital to be aware of when an insurance company is improperly refusing to honor obligations under the policy.

What Additional Sources of Information Do Insurers Use to Deny Claims?

With so much money at stake in a disability claim, insurance companies invest in additional investigations to try to find justification for denying the claim. They will frequently tell claimants that they need to undergo an “Independent Medical Examination” to provide objective evidence of their condition. However, since the insurer chooses and pays for the doctor, the exam is not independent or impartial. The doctor performing the exam will be inclined to look only for factors that support the insurance company’s interests.

Insurance company investigators also conduct surveillance on claimants to see if they can catch them doing something that reveals that their disability is exaggerated. They will even go through social media with facial recognition software looking for “evidence” that your limitations are not genuine.

How Do You Appeal a Denial Successfully?

To obtain benefits after a disability insurance claim has been denied, you need to:

• Request a timely administrative appeal
• Analyze the denial letter to determine the issues of contention
• Obtain new evidence
• Present all your evidence at the administrative appeal to address the issues raised by the insurer and further strengthen your claim
• If the result is not favorable, file a claim in state or federal court
• Take advantage of opportunities in the litigation process to obtain additional information
• Present your best arguments to the court to show why benefits are justified under the terms of the policy

Below, we highlight some of the most critical steps in the process.

What Do You Need to Look for in the Denial Letter?

The denial letter from the insurance company should clearly explain why they are refusing to pay your claim, so you need to examine it carefully to identify any issues they may be using as grounds for the denial. There is likely to be more than one potential problem, but you may need to read between the lines to determine what that problem is. This is one reason it is so helpful to work with an experienced attorney during the appeal: your lawyer can not only spot the issues but should also know how to overcome them.

Why Is It So Critical to Present All the Evidence During the Administrative Appeal?

Evidence not submitted during the administrative appeal may be excluded later, so it is wise to make the effort to acquire all the evidence you can before the administrative appeal. When you go through an administrative appeal, you are asking the insurance company to review your case again. It may seem obvious that if they want to deny your claim, they will simply do so, and for that reason, many people believe they don’t need to do anything differently.

But that approach can trap you. Regardless of whether the insurance company reaches the same conclusion after reviewing your new evidence, by introducing that evidence, you have made it part of your official record that can be reviewed again later on by a judge. If your policy is governed by ERISA rules, then you will probably not be able to introduce any new evidence after the administrative appeal. Even if you are allowed to do so, it often carries more weight when introduced earlier in the process.

What Happens if Litigation Becomes Necessary?

If the outcome of the administrative appeal is another denial or an offer of benefits that is not in line with policy terms, then your attorney should have laid the groundwork for a successful appeal in court. If your policy is provided through an employer and governed by ERISA, then your appeal will be in federal court, but if your policy is an individual policy, then the case will likely be filed in state court.

Most of the litigation process occurs out of the courtroom before the date of the trial. Attorneys conduct legal proceedings to acquire information and try to gain legal advantages. The process frequently proceeds as follows:

• Your attorney files a complaint with arguments in court and receives a formal answer
• Both sides may exchange documents requesting information which must be supplied in accordance with legal requirements
• The lawyers submit additional arguments to the court asking for judgment
• The judge conducts a review of the briefs and administrative record and may rule on some or all of the issues

A live hearing may be conducted where arguments and evidence are presented in person, but in many cases, the issues are settled in writing.

FAQs About Disability Appeals

How long does a private disability insurance appeal usually take?

The duration depends on the type of policy and the cooperation of the insurance company, but you should expect it to take at least several months. You will need time to obtain your best evidence, and then you need to give the insurance company approximately six weeks to review that evidence (more if they request an extension) If the case is appealed in court, it could potentially take a year or more to resolve, but your attorney can explain the likely timeline in your particular case.

Do all disability appeals go to court?

No, many appeals are resolved through the administrative appeal process or negotiated out of court.

How are ERISA appeals different from private disability insurance appeals?

The laws that govern these policies are different, so that means deadlines for filing are often different. One of the key differences is that the right to appeal the insurance company’s decision in court is very limited with an ERISA policy, so it is vital to present solid evidence and arguments during the administrative appeal.

Seltzer & Associates Understands How to Succeed with High-Stakes Disability Appeals

While it is helpful to work with a knowledgeable disability insurance attorney at the start of the claims process, it is particularly vital to seek the right legal assistance when appealing a denial. There are few firms anywhere in the U.S. that can match the knowledge and experience Seltzer & Associates can provide in this situation.

Whether your policy is an ERISA policy provided through your employer or a private individual policy you purchased independently, we know how to take advantage of every aspect of the appeal process to obtain the benefits you deserve. Schedule a free consultation to learn more about the assistance our team can provide.