Claims made for short term disability and for long term disability benefits are frequently denied by ERISA plan benefits administrators.  Congress enacted ERISA to provide a level of minimum standards for most voluntarily established retirement, disability and health plans in private industry to provide protection for individuals in these plans.  To help achieve that goal, ERISA provides claimants with rights and protections, including the right to timely appeal an adverse benefits decision, such as an improper denial of benefits, and it imposes procedural requirements on ERISA plan administrators to ensure that claimants are given the opportunity to obtain the benefits that were promised and for which they had paid.

If your disability insurance coverage is not subject to ERISA, perhaps because you work for an employer in the public sector or you purchased individual disability coverage on your own and not through your employer, the basic steps to prepare your appeal are similar.  The insurance company has a duty to communicate with you in good faith and provide you with all relevant information regarding its denial of the claim, and it can be sued for “bad faith” if it fails to comply with its obligations.

You want to know what you can do to assure that your claim is administered fairly and, hopefully, approved.  There are a few key things that disability claimants must do to give themselves the greatest chance of success in getting their claims approved after an initial denial, but the most important thing, short of hiring experienced ERISA disability attorneys and aggressive disability insurance bad faith attorneys, is to make sure that you provide the plan administrator with as much evidence as you can of your disability so that this information will be included in your administrative record.  This is especially critical in ERISA cases because the determinations in them often rest solely on the contents of the plan administrator’s administrative record when your case is litigated in federal court.

Below is a list of things that should generally be done by a disability claimant who has been wrongfully denied ERISA disability benefits:

1. Request a copy of the administrative record
2. Obtain a copy of the governing ERISA plan documents, if applicable, and the disability insurance policy
3. Carefully review the denial letter
4. Outline the bases for the improper denial of benefits
5. Martial evidence that supports your claim, making sure to address ALL of the stated bases for the denial

Send a letter to the plan administrator and insurer requesting a complete copy of the administrative record and the claim file

ERISA claimants who are denied benefits are entitled to receive a copy of the administrative record, and the plan administrator is generally required to provide it to them within 30 days of receipt.  If the plan administrator fails to respond within that timeframe, it has violated the ERISA regulations and may be subject to statutory penalties.

In cases that are not subject to ERISA, disability insurers will sometimes provide you with a copy of your claim file.   However, most insurers will not provide you with a copy of the claims file because they are not required to do so under the law.  If your insurer refuses to produce the claims file to you for your appeal, you will have to do your best to challenge the appeal without the claim file.  It is especially important to hire competent ERISA disability attorneys when you want to prosecute an appeal under these circumstances.

Review the claims file and administrative record carefully, focusing on the reasons the plan administrator used to deny your claim and take appropriate action

A plan administrator is required to state all of the reasons it denied your claim.  The denial letter and the administrative record will serve as a roadmap for the evidence you need to successfully appeal your claim.

For example, if the denial letter indicates that the plan administrator was unable to obtain medical records that are important to your disability claim, you will need to follow up and make sure that those records are included with your appeal.  Often the denial letter will state that the plan administrator’s medical consultants had attempted to contact your treating physicians, without success.  In that case, following up with a statement from your treating physician may serve to underscore your eligibility for benefits and discredit the broad and self-serving statements by these paid medical reviewers in the administrative record and in the denial letter.  Insurers normally use medical consultants, often referred to as “paper reviewers,” to review your medical records and render an opinion as to your medical conditions and your restrictions and limitations.  These paper reviewers are typically “hired guns” who know what their hiring insurers want to hear.  You should focus your attack on their medical review, attempting to undermine their opinions as best as you can.

Prepare your own summary of your actual job duties

The denial letter is required by law to indicate why the disability plan administrator believes you are not entitled to benefits.  Sometimes incorrect denials are made because the plan administrator is not considering an accurate description of the requirements of your particular job.  If so, it is necessary to correct that misunderstanding.   You may also be able to provide additional support for your description of your own occupation from your employer or co-workers.  If necessary, you could ask them to explain why your particular disability prevents you from doing your job and to confirm that your description of the job requirements is more detailed and accurate than the information the plan administrator relied upon to deny your claim.

Write a detailed description of, and get your doctors to certify, how your disabling condition or conditions interfere with your everyday life and prevent you from performing your own occupation or any occupation

Insurance companies are required to review and evaluate personal statements from disabled individuals and others who have perceived the impact of the disabling condition.  It is important for you to write a detailed statement that helps fill in the blanks in the medical records.  Medical records of your treating providers will usually not contain the level of detail that you can provide to support your claim, in part, because your treating providers are focusing on the treatment, and not on the disability.  Letters from your treating providers can be very powerful evidence of your disability if you are able to get them to draft them to address the mistaken conclusions of the medical professionals who were hired by the insurance company to review your medical records.  Your employer, friends, and coworkers may also be able to provide letters that provide the insurance company with facts to support your claim.

Draft a detailed letter that addresses the reasons the insurance company denied your disability claim and include all of the additional medical records and supporting statements you have obtained with it

It is important to present your disability claim thoroughly and accurately and to focus on the stated reasons for the denial.  Additional medical records and certifications from your doctors or other treating professionals should be attached as exhibits to your letter.  It is also extremely important that you submit your appeal letter before the deadline.  The denial letter should contain this information.  It is also very important to request an extension of time to submit your appeal letter if you need one.

In summary, there is a lot of work involved in preparing an appeal letter that maximizes your chances of winning the appeal.  This article has only provided a rough outline of the things that can or should be done in many cases to prepare a winning appeal.  Obviously, every disability claim is different, and the appeal letters will differ based on the specific reasons for the denial and the evidence.  Because of the complexity of the task, many disability claimants choose to hire an experienced ERISA or bad faith insurance disability attorney to help them navigate the appeal process and to prepare their appeal letters.  McKennon Law Group PC’s practice focuses on disability insurance claims and has substantial experience dealing with disability claims against most, if not all, major disability insurers.  If you have any questions regarding your recently denied insurance claim, you can contact us to arrange for a free consultation.