Long Term Disability Appeals | The Basics

Disability Wiki.

You’ve applied for Long Term Disability benefits and your claim was denied, or your LTD claim was initially approved, but the insurer terminated your benefits after a certain number of months or years. What is your next step?  As annoyed as you may be, you unfortunately cannot just sue the insurance company.  The federal law known as ERISA requires that you first appeal the insurer’s adverse determination.  

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At Riemer Hess, our disability insurance attorneys know what is necessary for a successful appeal. We prepare appeals as if they were cases in court.  We have found that if you submit a comprehensive appeal, you show the insurer you are serious and have a better chance to win.  We are aggressive in our appeal approach, and will help you obtain the proof you need to counteract the private disability insurance company’s reasons for the denial and to prove you are unable to work in your own or any occupation.

Is there a deadline to submit your appeal?

Yes, ERISA requires insurers to give you a minimum of 180 days (measured from receipt of the denial letter) to submit your administrative appeal. As mentioned above, ERISA requires you to submit at least one appeal. If you do not submit your appeal within the 180-day deadline, the insurer will deny it as untimely. In addition, the failure to submit an appeal within this timeframe could be treated as a Statute of Limitations violation, preventing a Court from reaching the merits of your case. It is, therefore, imperative that this deadline be satisfied.

What should you do when you receive a denial letter?

The first step following the receipt of the denial letter should be to request a copy of your claim file from the insurance company.  ERISA requires, upon your request, that insurer provide you, free of charge, with copies of all documents relied upon in the claim denial. The claim file generally consists of all documents used by the private disability insurance company (e.g., medical records, reports from your treating doctors, reports from the insurance company’s doctors (often called “Peer Review” reports), vocational assessments, transferrable skills analyses, correspondence, surveillance reports and videos, and the insurer’s internal claim notes (often called SOAP notes), etc.).  ERISA requires the insurance company to provide you with your claim file within 30 days of your request. In addition to the claim file, you also should request a statement of any additional material information necessary for you to perfect your appeal and an explanation why such material or information is necessary; a fuller explanation of the reasons for the denial; and a demand that all electronically stored information regarding the you and your claim be preserved.

How long will it take for my insurance company to make a decision on my appeal?

Once your appeal is submitted, the insurance company has up to 45 days to render a decision. However, this deadline could be extended for an additional 45 days if the insurer sends you a letter stating there are special circumstances requiring the extension (e.g., your file may still be under review by the insurer’s doctor or the insurer may have requested a vocational review). Therefore, in reality, you should be prepared to wait about 90 days for a decision on your appeal.

Contact Our Disability Insurance Attorneys Now

If you have any further questions regarding appeals parameters, we can help. Our knowledgeable disability insurance attorneys will dedicate the time and energy you deserve. Call Riemer Hess LLC, Attorneys at Law, today at 212-297-0700.

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