Preparing An Appropriate Appeal Of Your Group Disability Insurance Claim Denial

It is essential that you understand the importance of preparing an appropriate appeal of your group disability insurance claim denial. Most group disability insurance policies fall under the Employee Retirement Income Act of 1974 (“ERISA”). ERISA provides extremely strict deadlines and guidelines for claimants and insurance companies to abide by in the processing of a claim, submission of an administrative appeal, and in the ultimate determination of eligibility for benefits under a disability insurance policy. If a claimant does not adhere to these strict guidelines and deadlines, the result can be disastrous for the claim. Unfortunately, while insurance carriers are not free to ignore their obligations under ERISA, often claimants are unaware of their rights and violations often go unchallenged.

Unlike private disability policies, when a claim for disability benefits governed by ERISA is denied, the claimant MUST appeal directly to the insurance company that originally denied the claim. In some circumstances, a third party administrator reviews the appeal. However, ultimately the decision usually lies with the claimant’s insurance company. Failure to submit an appeal can mean the end of your claim. In such a case, you will usually not be able to sustain a lawsuit against your insurance carrier for its wrongful failure to provide benefits.

ERISA appeals should never be taken lightly. Most ERISA disability insurance claims allow the claimant 180 days from the date of receipt of a denial correspondence to appeal the insurance company’s decision. While six months may seem like a long period of time, given the amount of information typically necessary to prepare an effective ERISA appeal, it is essential that you not waste any time. In a private disability insurance claim, if you are denied benefits by your insurance company you can file a lawsuit, gather all of your evidence for trial, and present it to the judge or jury. Evidence brought forth at trial usually includes medical documentation, treating physician testimony, medical and vocational expert opinions, testimony from co-workers, friends, and family members who understand your condition and limitations, and employment documentation. It can take up to two years to properly prepare for trial. However, in ERISA disability insurance claims you must do all of this during the appeals process. This is because under most circumstances an ERISA disability insurance trial is based SOLELY on the information submitted prior to and with the ERISA appeal. Typically, if a claimant fails to provide any relevant information prior to or with the appeal and the insurance company upholds its denial of benefits, the claimant will be forever barred from bring forth the new evidence at trial. Thus, in most cases, it is essential that you prepare your trial in the six months that you have to appeal your insurance carrier’s denial of benefits.

Many claimant’s, unaware of this fact, merely submit a letter from their treating physician disputing the disability insurance carrier’s determination and / or provide updated medical records. Oblivious of the rights they are giving up, many truly disabled individuals severely damage their claims for benefits. Most individuals would be weary of basing their entire lawsuit on the meager evidence described above. While under certain circumstances the administrative record can be re-opened, allowing additional information in, it is essential that you understand the possible damage that can be done to your claim by failing to prepare an effective and thorough appeal of an ERISA governed disability insurance claim. Insurance companies often have “independent” medical reviewers provide an opinion of your documentation. It may be important to counter this information with a truly independent physician review, an independent medical examination, and/or a vocational expert opinion. At Disability Insurance Law Group, we prepare every appeal with the information we would need to present at trial.

Insurance carrier’s typically have 45 days to make a decision on your ERISA appeal. Insurance carriers are also allowed to take an extension of up to 30 days for good cause shown. Moreover, under most circumstances, insurance companies are limited to the original reasons set forth in the first denial of benefit correspondence and are not allowed to put forth new reasons for a denial of benefits if no additional appeals are provided to the claimant.  Often insurance companies will miss these deadlines and wrongly delay payment of a claim.  If a claimant is unaware of their rights, these violations may go unchallenged.

Insurance carriers typically do not tell claimants that they must prepare an entire trial during that 180 days provided to appeal the denial. As such, it is essential that claimants clearly understand the importance of the appeals stage and the time constraints that they are under.

Not all group disability insurance claims are governed by ERISA. However, because of the strict guidelines and deadlines that ERISA places on claimants, many insurance carriers assert that the claim is governed by ERISA, even if it clearly meets one of these exceptions. If claimants are unaware that their claims are not governed by ERISA, they may be unnecessarily delaying the payment of benefits or unknowingly giving up many rights. However, if you are unsure of whether your claim actually falls under ERISA, it is highly recommended that you seek advice from a legal professional before disregarding any ERISA deadlines.