Receiving a denial of your long-term disability claim can be devastating, especially when you are already struggling with a serious medical condition that prevents you from working. However, a denial is not necessarily the final word on your claim. ERISA regulations provide specific appeal rights that allow you to challenge the insurer's decision and present additional evidence supporting your entitlement to benefits. Understanding this process and pursuing it effectively gives you the best chance of overturning an improper denial.
Understanding ERISA Appeals
Most employer-sponsored LTD policies are governed by ERISA, which requires insurers to provide at least one level of internal appeal before you can file a lawsuit. This administrative appeal process is mandatory, and you cannot skip it and go directly to court. The appeal gives you an opportunity to submit additional evidence and arguments, and the insurer must conduct a full and fair review of your claim.
ERISA regulations require the insurer to provide specific information in the denial letter, including the reasons for denial, the specific policy provisions relied upon, any additional information needed to perfect your claim, and an explanation of the appeal procedure. If your denial letter lacks this information, that itself may be grounds for challenging the denial.
Time Limits for Appeals
ERISA typically provides 180 days to file your appeal after receiving a denial. This deadline is critical because missing it can permanently forfeit your right to challenge the denial. Mark the deadline on your calendar as soon as you receive the denial letter, and begin preparing your appeal immediately even if you also consult with an attorney.
The 180-day period usually begins when you receive the denial letter, not when it was sent. Keep the envelope showing the postmark date, as this may be relevant if there is any dispute about when you received the letter. If you need additional time to gather medical evidence, you may be able to request an extension, but do not assume one will be granted.
Analyzing the Denial Reasons
Effective appeals address the specific reasons the insurer gave for denial. Read the denial letter carefully to understand exactly why your claim was rejected. Common denial reasons include insufficient medical evidence, failure to meet the policy definition of disability, alleged ability to perform sedentary work, and pre-existing condition exclusions. Each reason requires a different response strategy.
Request your complete claim file from the insurer, which ERISA requires them to provide. This file contains all documents, records, and information used in making the decision. Reviewing the file reveals what evidence the insurer considered and may identify gaps or misunderstandings that you can address on appeal.
Strengthening Your Medical Evidence
Medical evidence is usually the most important factor in LTD appeals. If the denial cited insufficient evidence, work with your treating physicians to provide more detailed documentation of your condition and limitations. Ask your doctors to write narrative reports explaining your diagnosis, the objective findings supporting it, your functional restrictions, and why you cannot work.
Consider obtaining additional medical evaluations if your current evidence is weak. A functional capacity evaluation objectively measures your physical abilities. Neuropsychological testing documents cognitive limitations. Expert opinions from specialists in your condition can counter any adverse opinions from the insurer's reviewing physicians. New evidence not available during the initial claim review can be submitted on appeal.
Addressing Vocational Issues
If the insurer claims you can perform other work despite your limitations, you may need vocational evidence to counter this. A vocational rehabilitation expert can analyze your transferable skills, the demands of potential alternative occupations, and whether any jobs actually exist that you could perform. This expert analysis can demonstrate that the insurer's vocational conclusions are unrealistic or based on jobs that do not accommodate your restrictions.
Labor market research showing that the supposed alternative jobs either do not exist in significant numbers or would not be available to someone with your limitations strengthens your appeal. The insurer may have relied on generalized job descriptions without considering whether you could actually perform the work given your specific combination of age, education, experience, and functional restrictions.
Writing the Appeal Letter
Your appeal letter should systematically address each reason for denial and explain why the decision was wrong. Cite specific policy language and explain how the evidence supports your claim. Reference particular medical records, test results, and physician opinions that contradict the insurer's findings. Be specific and factual rather than emotional or argumentative.
Organize your appeal clearly, with separate sections addressing each denial reason. Include a list of all new evidence being submitted and explain its relevance. If the denial relied on an in-house medical review, point out any qualifications gaps, errors, or contradictions with your treating physicians' opinions. Submit everything by the deadline with proof of delivery.
The Importance of the Administrative Record
If your appeal is denied and you file a lawsuit, federal courts generally limit their review to the administrative record compiled during the claims and appeal process. Evidence not submitted during the appeal typically cannot be considered by the court. This makes it essential to include all relevant evidence in your appeal, even if you are not certain it will help.
Think of the appeal as building your trial record. Everything you want a court to consider must be in the administrative file. This includes not only medical evidence but also any correspondence with the insurer, complaints about claim handling, and any evidence of procedural violations or conflicts of interest.
When to Hire an Attorney
While you can file an appeal without an attorney, legal representation significantly improves your chances of success, particularly after an initial denial. ERISA disability attorneys understand the specific rules and strategies that affect these claims. They know how to develop medical and vocational evidence, identify procedural errors, and present arguments effectively.
Many ERISA attorneys offer free consultations to evaluate your case. If they believe you have a strong claim, they may take your case on contingency, meaning you pay nothing unless you win. Given the importance of the appeal in building your record for potential litigation, consulting with an attorney before submitting your appeal is strongly advisable.