If ERISA applies to your long term disability claim, you have the right to request and review your claim file in the event of a denial. This is a critical right to exercise before filing your ERISA long term disability appeal. Having the claim file will give you valuable insight as to why your insurer denied your claim.What exactly is your claim file? Your claim file is a record of everything your insurance company evaluated before deciding on your long term disability claim.
The claim file includes:
- internal notes;
- vendor reports;
- medical records;
- policy documents;
- surveillance reports, and more.
Your insurance company is required to provide you your claim record free of charge. Many people do not realize they have a right to this information.
Here are examples of what you should be looking for in your long term disability claim file.
The Log of Internal Notes
From the start of your claims process, your insurance company keeps a log of internal notes. These are sometimes called SOAP (Subjective, Objective, Assessment and Plan) notes. The notes document every time your insurance company or one of their vendors worked on your claim. It also includes summaries of any phone calls and internal e-mails. These notes can be key for devising an appeal strategy. Often they will illuminate your insurance company’s reasoning for denying your claim – and sometimes that reasoning is at odds with your denial letter.
Correspondence with You
All letters and e-mails from your insurer should be included in your long term disability claim file. This can be helpful for many reasons. For example, make sure your insurer respected its own deadlines and gave you adequate time to respond to their requests.
Correspondence with Your Doctors
Any correspondence between your insurance company and your doctors should be found in your claim file. Sometimes your insurer will take your doctor’s words out of context. You want to see exactly what your doctor communicated to your insurance company. With the full context, you can make an argument during the appeal process.
Correspondence with Your Employer
Communications between your employer and your insurer should also be in your long term disability claim file. This allows you to verify your employer provided the correct information. Examples of this information include:
- Your last day of work;
- Your salary;
- Job description;
- Description of your work environment.
All of these factors can affect your claim being approved or denied. It is important to make sure everything from your employer was accurate.
Your Medical Evidence and Reports from Your Doctors
All medical records you submitted in support of your claim should be in your claim file. These include:
- Doctor office visit notes;
- Surgical reports;
- Attending physician statements;
- Pharmaceutical records, and more.
It is very important to check that all records you sent are included in the file. If any are missing, that means your insurance company did not take them into account before deciding your claim. They can be included when filing your appeal.
Reports from Your Insurer’s Medical Consultants
While reviewing your claim, your insurance company may send your medical records for a “peer review” from another doctor. This means the medical consultant looks over your medical records and gives an opinion without seeing you in person. Any reports from those medical consultants should be in your claim file. If your insurance company does not provide you those reports before denying your claim, this is an opportunity to see those documents.
The peer review will have:
- the consultant’s opinion;
- a list of what documents they reviewed to reach their conclusion;
- whether or not they spoke directly with your examining doctors.
What these reports say is important for an appeal. For example, check if these consultants were given your full medical records and whether they contacted your doctors directly for clarification on your condition(s). Otherwise you have an argument that their opinion was based on limited information and access.
Reports from Your Insurer’s Examining Doctors
Sometimes when determining a claim, your insurance company will send you for an Independent Medical Examination (IME). The resulting IME report should be in your claim file. Your insurance company may have used the results of your IME as justification for terminating your benefits or denying your claim. It is crucial to obtain that report. By seeing the IME doctor’s exact claims, you can argue against them in your appeal.
Reports from Your Insurer’s Vocational Consultants
Your insurer may solicit a Vocational Consultant for your case. Your claim must prove that you are medically unfit for your occupation. The Vocational Consultant is meant to assess whether your limitations prevent you from doing your specific job. Any report from a Vocational Consultant should be included in your claim file. The consultant’s opinion may have been used by your insurer to cut off your benefits or deny your claim. Look at the report for what they said, their credentials, and what information they were given. That way you can explain precisely why their opinion is not correct or credible. All of this will help strengthen your appeal.
Reports from Any Field Interviewer
If your insurer conducted a field interview – i.e., when an insurance company representative visits you for an in-person interview – there should be a full record of that interview in your claim file. This is useful to have so you can see if there are any discrepancies between your version of events and theirs. If anything was misrepresented, you can point it out in your appeal.
Footage and Reports from Any Third Party Investigator
Insurance companies sometimes hire third party investigators to perform surveillance. There are two main types of surveillance:
- Camera surveillance (being followed and filmed by an investigator)
- Social media surveillance (checking for anything you’ve posted on Facebook, Twitter, LinkedIn, etc.).
Your claim file should have all surveillance reports. The camera footage itself should also be included. Often this surveillance can be taken out of context to justify cutting off your benefits. Reviewing their footage, reports, and notes allows you to explain why they are compatible with your disability and restrictions.
Your Complete Plan Documents
Your claim file should have your complete plan documents. This includes your full policy, Summary Plan Description, policy amendments, and anything else. Review the plan documents in the file carefully and make sure they match up to the documents you have.
Any Other Guidelines Your Insurer Considered
Your insurer may use their own internal guidelines when reviewing claims. Examples are:
- Guidelines on how to evaluate your claim;
- How to determine the physical and cognitive demands of your occupation; and
- What they believe the expected timeframe for recovery from your disability should be.
If your insurer used any internal guidelines when deciding your claim, they should be included in your claim file. Make sure these internal guidelines are actually accurate and applicable to your occupation and disability.
Your ERISA long term disability claim file can be intimidating. Often they are hundreds, if not thousands, of pages long. However, it’s not about just looking for what’s there. It’s to see what is missing. Your appeal is a chance to include anything your insurance company might have missed.
It can be daunting to comb through your claim file if you don’t know what to look for. If you are looking to appeal a claim denial or termination, contact a qualified attorney to help you. A long term disability attorney can design a personalized strategy to win your claim and ensure you are set up for success. Don’t challenge your long term disability denial alone.