After making the difficult decision to cease working due to significant medical impairments, you decided to submit a claim for long-term disability ("LTD") benefits through your employer-sponsored disability insurer. However, your insurer sent you a letter indicating that it has denied your application for benefits. That is not the end of the road – the next step is to formally appeal the denial to your disability insurer. A disability claim appeal is an intricate process with the potential for errors that could jeopardize your LTD claim. The following are some common mistakes that must be avoided when submitting your LTD benefit appeal.
Table of Contents [ hide]
- 1. Submitting Your Appeal Before Reviewing Your LTD Policy and Claim File
- 2. Submitting Your Appeal Without Understanding Why Your Claim was Denied
- 3. Neglecting to Obtain Supportive Medical and/or Vocational Evidence
- 4. Missing the Appeal Deadline
- 5. Failing to Respond to New Evidence Generated After the Appeal Is Submitted
- 6. Nitpicking Over Factual Errors in the Denial Letter
- 7. Waiting to Hire a Disability Insurance Benefits Attorney
1. Submitting Your Appeal Before Reviewing Your LTD Policy and Claim File
The first step you should take after receiving the denial letter is to request your LTD policy and entire claim file from your disability insurer. You are entitled to those documents free of charge. Your LTD policy is important because it is the document that governs your LTD claim. It also sets forth the terms that you need to satisfy in order to be awarded LTD benefits, including a test of disability. Generally, you must demonstrate that you are unable to perform the main duties of your occupation to receive LTD benefits. Therefore, if you are to successfully appeal a wrongful denial of your LTD benefits claim, it is crucial that you know and understand the criteria you will need to satisfy to obtain those benefits.
Your claim file is equally as important to your appeal submission. The file consists of any documents that you submitted with your LTD application, including medical records, doctors' statements, and forms you completed. The claim file also includes any documents that your insurer relied upon, obtained, or considered when it assessed your entitlement to LTD benefits under your policy. That typically includes reports from physicians that the insurer hired to review your records and render a decision regarding your ability to work. Disability insurers also commonly rely on in-house vocational consultants that identify the duties of your occupation. Obtaining those documents makes certain that your disability insurer cannot hide anything from you. It allows you to verify that they received everything you submitted with your initial application.
2. Submitting Your Appeal Without Understanding Why Your Claim was Denied
Your disability insurer is required to communicate to you in its denial letter the specific reasons why it chose to deny your LTD claim. Understanding exactly why your claim was denied is pivotal for the purposes of your appeal. That is because to successfully overturn the denial on appeal, you will need to refute the insurer's evidence and identify what evidence will perfect your claim in the eyes of the insurer.
As referenced above, your disability insurer's denial will
be based on a medical opinion rendered by a nurse or physician who
reviewed your treatment records. The denial will also be based on a
vocational consultant's assessment of the duties of your
occupation. Oftentimes, those opinions can be based on a
misinterpretation or misunderstanding of your medical conditions or
the duties of your occupation. Therefore, you will need to point
out the errors present in those opinions and provide additional
evidence demonstrating why exactly those opinions were
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3. Neglecting to Obtain Supportive Medical and/or Vocational Evidence
A formal appeal letter is only a portion of what you must submit to establish your entitlement to LTD benefits under your policy. Your claim must be supported by medical and vocational evidence that proves you are unable to perform the duties of your own (or any other) occupation. Acceptable medical evidence that can support your inability to work includes medical records and statements from your treating doctors addressing specifically why you are unable to work. That evidence can also include residual functional capacity questionnaires completed by your doctors, as well as the results of a functional capacity evaluation testing your physical capabilities. If your disability is cognitive in nature, your claim can be supported by the results of neuropsychological testing. It is also helpful to provide statements prepared by individuals close to youregarding their first-hand impressions of your symptoms and resulting limitations. Those statements serve to corroborate the medical evidence that you submit with your appeal.
4. Missing the Appeal Deadline
In most instances, you will have 180 days from the date of the denial of your LTD claim to submit your appeal. However, it bears mentioning that appeal submission deadlines for most LTD benefit claims are currently impacted by the ongoing COVID-19 pandemic. The U.S. Department of Labor has extended the timeframe within which you must submit your appeal by instructing disability insurers to disregard the period from March 1, 2020, until 60 days after the declared National Emergency ends. As of the writing of this post, the National Emergency has not ended. The Department of Labor clarified in February of 2021 that an appeal submission deadline could not be extended beyond one year. Therefore, your 180-day window will begin to run either 60 days after the National Emergency is ended or one year after the denial of your claim.
It is critical that you confirm the exact deadline of your LTD appeal because there are severe consequences if you miss that deadline – failure to comply with the deadline will result in forfeiting your claim and any right to LTD benefits.
5. Failing to Respond to New Evidence Generated After the Appeal Is Submitted
In 2018, the U.S. Department of Labor amended the ERISA claims regulations to require that before a disability plan administrator may issue an adverse benefit determination on appeal, it must provide the participant with any new evidence generated after the appeal is submitted, or with a new rationale for the denial of benefits, and a reasonable opportunity to respond. 29 CFR § 2560.503-1(h)(4). This "new evidence" generally takes the form of a file review by a non-examining doctor (or doctors) and/or a vocational expert.
If you or your lawyer receives a letter from the disability insurer after the appeal is submitted requesting that you respond to new evidence, it behooves you to do so. Thanks to quirks in ERISA civil procedure, you likely will not have another opportunity to respond to this new evidence in litigation. Send a copy of the report(s) to your treating doctor and ask him or her to respond. Ask the disability plan administrator for additional time to respond, if necessary. Check to make sure the reviewing doctor received complete medical records and other evidence from the disability insurer, and supplement the evidence as necessary. If the reviewing doctor or vocational expert had incomplete evidence, or misunderstood the evidence, you have a compelling argument that his or her report should be set aside and the appeal approved. Likewise, if the reviewing doctor ignored your subjective complaints of pain, medication side effects, or the supportive opinions of your treating physicians, those are valid reasons for the report to be set aside.
6. Nitpicking Over Factual Errors in the Denial Letter
Too often, when disability claimants appeal a denial of LTD benefits on their own, they focus their energy on correcting mistakes and misstatements in the denial letter while losing sight of the bigger picture. Yes, it is important that the disability plan administrator have an accurate understanding of your medical history as well as complete medical records upon which to base its review. However, the nature of an appeal is that the prior decision is set aside and a new one is made, without deference to the prior determination.
Thus, rather than focusing on correcting factual errors in the initial denial letter, disability claimants will be better served by reviewing the disability claim file to determine the underlying reasons why the claim was denied (see #1 and #2, supra). Even if you don't have access to the claim file, a narrative statement regarding your medical history and symptoms and their impact on your daily activities, accompanied by new medical, vocational, and/or opinion evidence, is more compelling than a line-by-line rebuttal of the denial letter.
7. Waiting to Hire a Disability Insurance Benefits Attorney
As the above discussion suggests, disability benefits appeals can get very confusing very quickly. Therefore, it is best to err on the side of caution when attempting to secure your income while battling medical or psychiatric impairments that prevent you from working. You should consult an experienced disability benefits attorney who can guide you through the complex appeal process and be sure that you receive the LTD benefits to which you are entitled.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.