Appealing a Denial of Long-Term Disability & Protecting Your Legal Rights
Just because a policyholder pays premiums to an insurer does not necessarily mean that their claim will be easily approved. This is no less true of long-term disability benefits than other forms of insurance. However, a person with a disability should not lose hope if they receive a denial of their initial claim. This does not always mean that a claim lacks merit, and many claims succeed on appeal. If a policyholder does not recover benefits through the appeals process within the insurance company, they may be able to sue the company in court.
Before appealing a denial, a person with a disability should understand why the claim was denied. This will help them develop a strategy to reverse the outcome. For example, perhaps the insurance company denied the claim because it did not have the required information to evaluate it. In this case, the policyholder might simply need to provide the insurer with the missing information. Other reasons why a claim might be denied include:
- The evidence does not show that the policyholder is disabled as that is defined in the policy
- The policyholder is disabled due to a pre-existing condition or another condition not covered by the policy
- The policyholder is not receiving medical treatment
- The disability has not yet lasted long enough
The denial letter should cite the section of the policy supporting the denial and tell the policyholder about the process of filing an appeal, including any key deadlines.
Evidence for Appealing a Denial of Long-Term Disability Benefits
A policyholder might be able to strengthen their case by providing further medical records. In some cases, the insurer might not have received or reviewed all of the relevant records for the initial claim. If any records were missing, the policyholder can include those records with the appeal. In addition, they might want to find out whether more tests would strengthen their claim for benefits if it was denied based on inadequate evidence. A claimant also could get opinion letters from their doctors on the effects of their disability on their capacity to work.
Not all types of evidence may come from health care providers. While an insurer probably will find a letter from a doctor especially persuasive, a claimant also might submit letters from family members and friends on how their condition limits their activities. They might be able to provide an opinion from a vocational expert on their inability to work.
The Value of Legal Representation in LTD Appeals
A person with a disability should retain an attorney if their dispute with the insurer ends up in court. Even before then, though, they may want to secure legal representation. An attorney can help gather evidence and shape it in a strategic way. For example, they might be able to provide a doctor with a questionnaire that helps them focus their opinion letter on the most relevant areas of the claimant’s limitations. An attorney also can help with meeting deadlines and complying with other procedural rules, ensuring that an appeal does not fail based on a technicality. On a more superficial level, hiring a lawyer signals to the insurer that the policyholder is taking their claim seriously. This may discourage the insurer from engaging in dubious tactics to avoid payment.
Some claimants may worry about the cost of legal services, but most of these attorneys charge their fees on a contingency basis. This means that they do not get paid unless the client recovers benefits. They collect their fee as a percentage of the amount recovered. A claimant thus might even consider hiring an attorney to assist with their initial claim and increase the chance of avoiding the appeals process altogether.
