Filing an Appeal of ERISA Long Term Disability Denial 


You just received a denial letter from your disability insurance company (Hartford, Unum, Reliance, Guardian - whoever the company is). It says that your policy is governed by ERISA (a federal law) and you have been denied or your benefits terminated and lists a bunch of reasons for the decision. Here are 6 basic steps in filing your appeal.


Let's go. The clock is ticking. Since we're talking about ERISA governed plans, you probably have 180 days to appeal (your denial letter should say that). For what you have to do - review the claim file, work with experts, create the evidence, research the plan, and file the appeal, that isn't much time.


Unlike some insurance claims or injury cases, we don't recommend that you appeal yourself. The law and process just favors the insurance industry too heavily, and there are all kinds of traps.


Plus, in most cases, the appeal is your one and only chance. If that is denied, you need to file a lawsuit in Federal Court, where no new evidence will be allowed - the federal judge will decide the case based on the administrative record, which is your appeal. That's why the appeal is so critical.


If you have questions about this complicated process just call us at (202) 393 - 3320.


1. Determine Whether Your Disability Policy is ERISA or Non-ERISA


The letter you received from the insurance company denying to ending your benefits should tell you if your policy is governed by ERISA (a federal law, the Employee Retirement Income Security Act). This is important to determine right away because there are different rules and deadlines that apply to ERISA cases. Basically, if you work for a government agency or local public school system, your long-term disability policy is probably not governed by ERISA, but there are still special rules for those types of claims. If you work in the private sector and are covered by a disability policy through your job, your claim is probably covered by ERISA.


2. Calculate and Calendar the Date Your Appeal is Due


This is important - your appeal is due to the insurance company by a date certain. It's like a statute of limitations, you only have so much time to file the appeal and not filing in time will probably end your claim for good. Your denial letter should give you the time limit for the appeal, and it will depend on whether you have an ERISA covered policy or not.


A word of caution is in order - it's not enough to just send a letter or form that says "I appeal your decision" or something similar. As you will see, your appeal is a comprehensive report and compilation of new information, medical and vocational reports, new evidence, etc. that supports your position that you are disabled as defined by the terms and conditions of the policy. This is what will be used to evaluate your appeal (and the record if you are in federal court on your case).  

3. Request Your Entire Claim File and Related Documents from Your Employer

You need to review and analyze your claim file in detail to determine mistakes, inconsistencies, or what the disability insurance company overlooked in the evidence. Depending on whether you were receiving benefits and the type of injury or medical condition you have, this file can be hundreds and hundreds of pages. Initially, your analysis of the claim file should focus on:

  • Are there documents that are missing that ERISA requires
  • Does the denial letter address your specific medical condition
  • Does the denial letter accurately describe your job
  • Does the denial letter accurately describe your limitations
  • Did the insurance company use the correct medical specialty for your condition

These are a lot more things to identify and address of course, but these are a few basic factors to get started.


4. Conduct Specific Medical, Legal and Vocational Research to Use in Your Appeal.


This is a lot. You may be reviewing and analyzing peer reviewed medical journals, expert medical reports and analysis, vocational statistics, Labor Market Surveys, and other records, data and literature. You're doing this for several reasons, including to make sure the insurance company has evaluated your specific condition or injury, limitations, your job functions, etc. and to determine the qualifications and bias, including financial incentives, of insurance company experts who evaluated your records.


5. Review Your Claim File Including Medical Records, Video Surveillance, and other Documents


Through your well researched, documented written appeal, you are trying to convince the insurance company that you are disabled and can't work under the terms of your long-term disability policy. You really need to drill down on that claim file and counter what is in there. You should be reviewing all of your medical records, the insurance expert medical examiner reports, job descriptions, transcripts, email chains, video surveillance (many insurance companies hire private investigators to monitor your activities and film you). Some people don't know how far the insurance company will go to avoid paying legitimate claims including spying on you.


Now if you're faking, and the video shows you working another job for example, there is nothing you can do about that (and don't call us - we're not interested). But usually the surveillance video shows you going to the grocery store, not performing activities outside your restrictions, and they often have to do days of surveillance, where you are doing absolutely nothing, to get 5 minutes of video. Generally, you're showing the insurance company all of the evidence they ignored, and giving them more to consider in the appeal. Remember, they pick and choose information they use to deny your claim.


6. Organize All of the Evidence, Draft and File Your Administrative Appeal By the Deadline


Organize all of the information you discovered or had created and after reviewing and analyzing it all as part of your appeal package, send it to the insurance company with your well drafted appeal. Your appeal should have everything you believe helps your claim in it because this is your one chance. If the appeal is denied by the insurance company and you file your case in federal court, you can't add new evidence. There is no jury trial or ability to surprise a witness in these cases, so put everything into the appeal. All of the information should support your best legal, procedural, medical, vocational arguments that you are entitled to disability benefits under the policy. You should counter the reasons the insurance company gave for denying your claim or terminating benefits.


And file it on time!


A Quick Tip for Your Long Term Disability Appeal


This process can be overwhelming, especially when dealing with a serious medical condition or injury and the financial strain of a denial letter. But take action to help yourself. Reach out to us for more information and we can help you take this one step at a time, removing some of the stress and anxiety along the way. Remember, if your appeal is unsuccessful, you will need to file a lawsuit in federal court. You can call a lawyer at that point, but if you are this far in the process and have made any mistakes in the appeal, haven't included everything, or just sent a letter saying "I appeal", a lawyer may not be able to help you.


So before you try to analyze and draft an appeal yourself, contact us at (202) 393 - 3320 to see if we can help. But don't wait. The clock is ticking.

Frank R. Kearney, Attorney-at-Law
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Experienced DC Workers' Comp, Long Term Disability & Accident Lawyer