Are you afraid your ERISA insurance company will arbitrarily deny your appeal? At Riemer Hess, our New York disability lawyers help our professional and executive clients navigate the complex appeals process and protect their rights.
To win an appeal is a daunting task. You need to convince the appeal unit of an individual policy insurance company to pay a claim that will cost the insurer money, all after the claims department has already decided not to pay. Recognizing that extraordinary action is required, we file comprehensive appeals specifically designed to change the claim dynamic. Here is what we do.
- Assessment and Appeal Strategy. We will sit down with you to assess the merits of your appeal and to propose a comprehensive appeal strategy. As more information comes in, particularly the individual policy insurance company’s claim file, we will continually refine the strategy making sure that all productive avenues are pursued.
- Demanding Documents from the Insurance Company. We write the individual policy insurance company demanding a copy of: the plan; the policy; the SPD; the claim file; all documents relied on by the insurer in denying the claim; any internal guidelines used by the insurer; the reports of all medical and vocational reviewers; audio or videotapes of the claimant; and notes of any telephone conversations. We request this information because we need to know about all damaging and potentially helpful information. We usually receive this information from the insurer within 30 days. If the information is not timely provided, we send follow-up letters creating a written record of the insurance company’s lack of cooperation.
- Demanding Specific Reasons for Denial. We write the insurer demanding that they provide us with a more specific description of the reasons for denial. Often the initial denial letter only states that there was insufficient objective evidence in support of your claim. Our letter demands that the individual policy insurance company tell our New York disability lawyers precisely what objective information is missing. If they tell us, we endeavor to provide it to the insurer during the appeal. If they do not give us a direct answer, we send follow-up letters creating a further written record of the insurer’s lack of cooperation.
- Gathering Records. We write your doctors requesting copies of all of your medical records. Often the individual policy insurance company does not request your doctor’s treatment notes prior to their denial. These notes may corroborate your symptoms. It is important that a complete set of your medical records is obtained.
- Additional Testing. In order to provide more objective support for your claim and to effectively change the claim dynamic, we recommend additional testing. If you suffer from cognitive deficits, we refer you to a neuropsychologist for neuropsychological testing to objectify your deficits. If you suffer from fatigue and/or pain, we refer you to a physical therapist to document your impaired functional capacity. We also refer all of our clients to a vocational expert to ascertain the material duties of your occupation and to explain why your restrictions and limitations prevent you from satisfying those material duties.
- Medical Reports. We procure opinion letters from your treating physicians explaining in detail why you are disabled. We also send your doctors customized questionnaires so that your doctor could provide very specific opinions about your inability to work. We also help your doctors address the concerns raised by the individual policy insurance company in its denial letter. To be successful in the appeal process, every concern raised by the insurer must be addressed. Nothing can be ignored.
- Client Affidavits. Our New York state disability attorneys spend a lot of time drafting a comprehensive affidavit for your signature. The affidavit is your opportunity to describe the duties of your job, to describe your symptoms, and to explain why your symptoms prevent you from doing your job. We want the affidavit to make your case come alive, to let the reader know who you are, and how your symptoms have affected your life, both at home and at work. It is much harder to deny your individual insurance claim policy when you are seen as a living breathing individual, rather than a claim number.
- Client Videotapes and Photos. We on occasion procure and submit videotapes and/or photos of our clients, particularly when they suffer from a disability that is apparent when seeing them in person. The saying is very true, “a picture is worth a thousand words.”
- Corroborating Statements. Most of our clients have family, friends and coworkers who have observed and witnessed their disabling symptoms. We procure statements from these individuals as an added way of corroborating your symptoms. Statements from coworkers (especially bosses) are particularly helpful because they provide direct proof of your inability to perform the duties of the job.
- Scientific Articles. We often conduct research of scientific articles and journals to help provide additional support for your condition. Our New York state disability lawyers often seek the assistance of your treating physician in this research.
- Scoring the Videotape. If the individual policy insurance company had you under video surveillance, we demand copies of the videos and spend time “scoring” them. Many claims are denied based on surveillance tapes that according to the insurer demonstrate that you are able to work because of the activities recorded on the video. By scoring the video, we are able to attack the video by putting it in perspective. When scoring the video we add up all the time on the video when you are shown walking, standing, sitting, etc. We then show that the combined amount is a minuscule percentage of the actual time of the surveillance. In other words, it is an insufficient sample to demonstrate that you are able to work.
The Appeal Letter
Once all of this information and proof is gathered, which could take weeks if not months, we prepare a comprehensive appeal letter. The letter will argue why you are totally disabled under the definition of disability in the policy and will attack all of the reasons for denial mentioned by the insurer. Although the appeal is formatted in the form of a letter, it is in every sense of the word a legal brief, complete with case cites, legal argument, and citations to the medical evidence.
Most of our appeals are granted. In the unlikely event that yours is not, your individual insurance policy claim is ready for court.
Keeping You Informed
Throughout the process, we at Riemer Hess keep you informed of all developments in your claim. We send you copies of all papers we send out, and copies of all papers we receive. We endeavor to return all telephone calls promptly. Throughout the process, we are mindful of what you are going through and try to make the process as easy as possible for both you and your family.