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Long Term Disability Appeal | Top Five Tips

Disability Wiki.

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You may only get one shot to win your long term disability appeal.  Don’t make the mistake of filing it without the advise of a skilled long term disability attorney.

Time and time again, unrepresented claimants unknowingly damage their long term disability appeals by: (1) neglecting to request and review a copy of your claim file; (2) failing to submit a timely disability appeal; (3) not submitting additional evidence; (4) failing to stay in treatment while the appeal is pending; and (5) being unaware that insurance company may conduct surveillance during the appeal.

Request and review a copy of your file.

If your claim is governed by the Employee Retirement Income Security Act of 1974 (commonly known as “ERISA”), then you have a right to review all relevant documents that the insurance company considered before denying your claim.  These documents are collectively known as the “claim file.”  Unfortunately, many unrepresented claimants fail to exercise this right to review the claim file.

The long term disability claim file will typically contain:

  • The medical records that the insurance company reviewed;
  • The plan documents that the insurance company relied upon;
  • Copies of your claim forms;
  • The job description that the insurance company relied upon;
  • Any information and/or documentation provided by your employer;
  • Medical reports from the insurance company’s consulting physicians and medical professionals;
  • Medical reports from the insurance company’s examining physicians;
  • Vocational reports from the insurance company’s vocational analyst;
  • Any written correspondence by and between your doctors and the insurance company;
  • Summarization of any telephone conversations between your doctors and the insurance company; and
  • The insurance company’s internal notes relating to your case.

Reviewing this information will allow you to understand why your long term disability claim was denied and give you the opportunity to address those reasons with your appeal.  For example, if the insurance company relied upon a flawed job description, you can obtain the correct job description to submit with your appeal.

Reviewing the claim file will help you identify what medical evidence was missing when the insurance company denied your claim.  Therefore, knowing what is in the claim file will provide you with the opportunity to gather the missing evidence and submit it for consideration with your appeal.

Make sure that your disability appeal is timely.

Many unrepresented claimants fail to realize that they must file the appeal by a strict deadline.  The deadline to file an appeal is typically 180 days from the date of the denial.  If you fail to file your appeal by the deadline, then the insurance company will likely finalize the denial.  If the insurance company finalizes the denial, then you may need to pursue litigation, which can be lengthy, costly, and very risky.   An experienced long term disability lawyer can advise you of your appeal rights and any applicable deadlines to ensure that they are met.

Submit additional evidence.

Insurance companies frequently cite "lack of sufficient evidence” as the primary reason for denial.  Unfortunately, many unrepresented claimants take this at face value and neglect to submit any additional medical evidence with their appeal.

If your claim was denied due to lack of sufficient evidence, then your appeal should seek to provide more sufficient evidence.  After all, the appeal is your opportunity to convince the insurance company that it was wrong.  If you do not provide additional evidence, then the insurance company is very unlikely to change its mind.

Notably, if your claim is governed by ERISA, the insurance company is obligated consider all relevant evidence that you submit.  This is true regardless of whether the evidence was submitted in connection with your initial claim on with your appeal.

Stay in treatment while your disability appeal is pending.

Many unrepresented claimants are unaware that the insurance company, or one of its consulting physicians, may contact your doctor(s) to discuss your condition while your appeal is pending.  If the insurance company learns that you stopped treating with your doctors while your appeal is pending, it will likely make certain negative assumptions.

These negative assumptions may include:

  • You improved and no longer require treatment;
  • You never required treatment and only initially sought treatment to bolster your claim; and/or
  • You are being non-compliant by refusing to seek treatment.

All of these assumptions are likely to result in a denial of your LTD appeal.  For these reasons, continuous and consistent treatment during your appeal is key.  An experienced long term disability lawyer can help advise you as to the type of physician you should treat with to best support your claim.

Be aware that insurance company may conduct surveillance.

Many insurance companies conduct video and/or photographic surveillance while appeals are pending.  The insurance company's goal is to “catch” you performing activities that are inconsistent with your disability claim.

For example, if your appeal argues that the insurance company was wrong about the severity, frequency and disabling nature of your headaches, then the insurance company may conduct surveillance in an effort to “catch” you going outside and engaging in activities of daily living, such as shopping, driving, walking your dog, etc.  The insurance company will then use that surveillance “evidence” to deny your appeal and uphold denial of your claim.

Seasoned long term disability attorneys know that such limited evidence can hardly suffice to prove an ability to work.  An attorney can rebut any surveillance evidence collected in connection with your claim, while also advising you how to avoid negative surveillance in the first place.

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