If your long-term disability claim has been denied or terminated, then you have the right to appeal the adverse decision under the Employee Retirement Income Security Act (ERISA). If you have any questions about the appeals process, you should not hesitate to consult with legal counsel because time is critical. You will have 180 days from the date you receive notice of the termination or denial of your claim to file your appeal. It is also important to note that a failure to file a timely appeal may preclude you from filing a lawsuit under ERISA.
Pursuant to ERISA, you are required to exhaust all “administrative remedies” before filing a lawsuit, which includes filing the appeal(s) as specified in your applicable LTD policy. If you fail to file a timely appeal, you may be deemed to have waived your right to pursue benefits in court. You may have only one opportunity to appeal an adverse decision.
The appeals process begins with the denial of your claim, or the termination of your benefits. The dreaded denial or termination letter is every disability claimant’s biggest fear, and potentially his or her worst nightmare. This notice may come at a time when you and your family are relying on your LTD benefits just to stay afloat. The insurer should promptly provide a written explanation as to why your claim was denied or terminated; however, the insurer will not provide a road map to reversing the company’s decision. Your appeal must be carefully constructed to support your claim while exposing any flaws in the insurer’s review. The first step is to obtain a copy of the administrative record and the insurance policy in effect. The administrative record or claim file should contain all of the information the company relied upon and used to make its adverse decision. This record may include hundreds or even thousands of pages of documents that should be carefully reviewed before finalizing and submitting your appeal.
It is important that you act promptly to understand the basis of the insurance company’s denial. Your disability insurance claim is governed by the terms, conditions, and limitations of your policy of insurance, as well as the applicable laws. 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 or terminate liability.
Unfortunately, most claimants lack the knowledge and resources to challenge the insurance company. At Seltzer & Associates, our team of lawyers works with our clients to obtain the necessary documentation to fully evaluate and 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 your insurance company’s claim file and to put your disability insurance company on notice of the issues that will be litigated should it fail to reverse its position during the appeal process. We may outline the deficiencies in the company’s review, including contractual and legal issues relevant to your claim. Upon submission of the appeal, we engage in an open dialog with the company to help expedite a full and fair review, and to obtain the most favorable result for our clients.
It is also important to note that the appeal phase may be the last chance you have as a claimant to include supportive documentation in the administrative record. Once you have exhausted all administrative remedies, your file will be closed and any supportive information not included in the administrative record may be excluded from the litigation process. In other words, additional supportive information may not be considered by the court in the event you proceed to filing a lawsuit. Thus, claimants must think quickly and strategically during every stage of the claims process beginning at the moment you are injured or become ill. What happens during one stage of the claims process will surely influence the next.
When it comes to LTD appeals, 180 days is not as generous a time frame as one may think. Filing an LTD appeal is a time-consuming and labor-intensive undertaking, especially when you are trying to ensure that the administrative record is properly documented with the strongest and most supportive medical and vocational information. It is never too early in the claims process to consult with Seltzer & Associates to ensure your claim is being presented in the strongest possible way to ensure you receive all long-term disability benefits you are entitled to.