You have jumped through every hoop, dotted every “i,” and crossed every “t,” but now the insurance company has informed you that your claim for short-term disability (“STD”) or long-term disability (“LTD”) has been denied. What’s next?
Most disability policies, and the federal law that governs many of them (the Employee Retirement Income Security Act, or “ERISA”) provide that you have the right to appeal the insurance company’s initial denial of your claim. If your claim is governed by ERISA, you have 180 days from the date you receive the denial to submit an appeal to the insurance company. This is a strict deadline. If you submit your appeal on the 181st day, the insurance company is not required to consider it.
What is the first step in preparing your appeal? If you did not receive the denial in writing, insist on a denial letter. The denial letter is supposed to inform you of all of the reasons why your claim was denied and your rights to appeal the decision. The letter will also tell you where to submit your appeal – it’s likely a different location than where you had been sending claim documents.
The denial letter will also inform you of your right to obtain a copy of your claim file from the insurance company. This is an important right. The claim file is supposed to contain everything that the insurance company considered in making its decision – emails, claim f0rms, authorizations, medical records, a copy of the policy, and other relevant information. Reviewing the claim file can tell you what evidence the insurance failed to consider or whether it even bothered to obtain your medical records. The claim file will help you determine whether you need to submit additional evidence when you submit your appeal.
An important consideration during the appeal process is determining whether you need additional evidence in support of your claim, and how to obtain it. If you are still under the regular care of a physician while your appeal is pending, it is almost always advisable to schedule one or more office visits before your appeal is due so that you can submit those records with your appeal. If you told the insurance company during the claim process that you had been seen by a specific provider, but their records are not in the claim file, you should request those records as well.
If you don’t appeal the insurance company’s denial, you will not preserve your right to sue them in court later if your appeal is denied. For this reason, insurance companies do things to discourage you from submitting a thorough appeal. Some companies will provide a one-page form and tell you that all you need to do is complete the form to satisfy the appeal requirement. However, good appeals are much longer than one page. There is no requirement that you utilize a specific form when submitting your appeal.
Finally, your appeal should focus on the denial letter and explain why the reasons listed for the denial are not applicable or are erroneous. The appeal is handled by a different department of the insurance company, and believe it or not, some companies will admit they made a mistake in initially denying your claim when provided with a persuasive appeal.
Appealing an initial denial of a disability claim is an extremely important part of the claim process and can be overwhelming, especially if you don’t know what evidence you need or what arguments to make. If you have been denied benefits and need to prepare an appeal, our team can help you increase your chances of finally getting approved.