If your short-term disability claim is denied, you need to speak with a lawyer as soon as you get that denial letter. A delay could mean losing out on your chance to file an appeal. You may have a short amount of time to do so, and the appeal process can be extremely challenging. Due to a federal law called ERISA, you may not be able to file a civil lawsuit and will instead need to follow a particular appeal process.
Do not go it alone. You’re injured, and your focus should be on recovery. When your disability claim gets denied, Sinclair Law Firm can restore your peace of mind. We’ll evaluate what happened and let you know what steps to take next to secure that temporary income replacement you need to recover.
If you feel that your disability benefits have been wrongfully denied, you can count on attorney Tom Sinclair and his team for help. To request a free claim review of your short-term disability denial, contact our Birmingham, AL law firm. You can also discuss your situation with us over the phone at (877) 249-0091.
Pay Attention to the Appeal Deadline in Your Denial Letter
Your denial letter will include a deadline to file an appeal. For short-term disability policies that are governed by ERISA, you will usually have 180 days to submit your appeal.
Think of that denial letter as a set of instructions or a road map. Apart from deadlines, these letters will also include the reason your short-term disability claim was denied, any missing documentation, and how to submit your appeal.
Why Were My Short-Term Disability Benefits Denied?
These are some of the most common reasons people are denied their short-term disability benefits.
- Your Claim Lacks Sufficient Medical Documentation: Insurers demand evidence that your disability is severe enough to prevent you from working. Claims can be denied if the evidence fails to demonstrate that your injuries impact daily life or work duties.
- You Do Not Meet the Policy’s Definition of “Disability”: Your policy may have strict definitions about what is considered a disability. If your condition doesn’t fit that definition, your claim can be denied.
- Your Condition Is Not Covered by the Policy: There may be exclusions in your disability policy that rule out coverage based on the nature of your injury or if drugs or alcohol played a role.
- Your Disability Is Disputed by an IME: An insurance company may have an independent medical examiner dispute the nature or severity of your injuries to deny a claim.
- You Have a Pre-Existing Medical Condition: Health conditions that existed prior to owning the disability policy could lead to a denial of disability coverage.
- Your Work History Does Not Qualify You for Coverage: Many short-term disability policies require a minimum work history for eligibility. If you have not met that requirement, your claim can be denied.
- You Have Not Followed the Prescribed Treatment Plan: Insurance companies expect you to follow a certain treatment plan to aid in your recovery. If you miss appointments or don’t keep records of these appointments, it could lead to a denial.
- You’ve Been Accused of Fraud or Misrepresentation: Insurance companies may accuse you of falsifying claims or overstating the severity of your injuries. This is why you need to be careful about what you post on social media and other public forums while seeking disability.
- Your Claim Is Incomplete or Lacks Key Information: If you made a mistake filling out paperwork or submitting a claim, your benefits could be denied.
- There’s Been a Change in Your Employment Status: If your employment status changed before you filed for short-term disability coverage, it could impact your eligibility for benefits.
- There’s Been an Error on the Part of the Insurer: Your claim could get denied through no fault of your own. When a claims representative makes a mistake, it’s up to the policyholder to file an appeal.
How to Appeal a Denied Short-Term Disability Claim
Here’s a brief rundown of how to file an appeal for short-term disability benefits.
- Consider Speaking with a Short-Term Disability Lawyer: We suggest that you speak with an attorney as soon as you receive a denial letter. Filing an appeal can be extremely complex, and a lawyer can help you navigate the process while avoiding time-consuming and costly mistakes.
- Request the Full Claim File: You have a right to receive your full claim file. This will show you the insurance company’s reasons for denying your claim, including their medical reviews and internal guidelines.
- Gather Supporting Documentation: You will need strong evidence that counters the reasoning in your claim file. This might include a letter from a doctor, updated medical records, new test results, and documentation about treatment.
- Craft a Clear and Persuasive Appeal Letter: Among many other things, your appeal letter will need to address the listed reason(s) why your claim was denied, with supporting evidence that disputes your claims.
- Make Copies of All Documents and Materials: Before you submit your appeal and supporting material, be sure to make copies of everything for your records.
- Submit Your Appeal via Online Portal or Certified Mail: When you submit your appeal, be sure to use a mailing method in which delivery can be confirmed or to use the recommended online portal.
Why You Need a Short-Term Disability Appeals Attorney
The appeal process can be stressful and complicated, especially when ERISA is involved. Most people don’t realize that their work benefits are subject to ERISA. In fact, your average person will have no idea what ERISA is unless they’ve had to deal with it themselves.
The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that applies to all employer-provided benefit plans. This may include your short-term disability coverage. This law was intended to protect employees, but insurance companies learned how to use ERISA to avoid paying benefits and create obstacles in the appeal process.
Whether you have an ERISA policy or a non-ERISA plan, it’s best to get help from the team here at Sinclair Law Firm. It’s worth restating: a short-term disability lawyer can help you navigate the process while avoiding time-consuming and costly mistakes.
What Makes the ERISA Appeals Process So Difficult?
Nothing about the ERISA appeal process is straightforward. You have limited deadlines and have to follow the procedures closely while trying to obtain your short-term disability coverage. Because of this complicated process, your appeal winds up being your one chance at receiving those denied benefits.
Short Deadlines to File an ERISA Appeal
As we’ve highlighted earlier, you generally have just 180 days to file an appeal if your ERISA short-term disability benefits have been denied. Failure to file an appeal within that 180-day deadline means you can no longer seek those benefits, even if you were wrongfully denied payment.
Your appeal must exhaust administrative remedies. That means the insurance company reviews the short-term disability appeal internally, and your appeal can still get denied. After you’ve exhausted administrative remedies, you can take legal action.
Unfortunately, there’s a catch.
Inability to File a Bad Faith Claim
Like many people, you’d assume that after exhausting administrative reviews, your next course of action is to file a bad faith insurance lawsuit. Well, not so fast. As a federal law, ERISA preempts state laws concerning bad faith claims.
ERISA laws mean that you cannot take your case before a jury of your peers to seek damages. Instead, your appeal goes before a federal judge. What’s more, you are only able to collect the disability benefits you are owed with no additional damages.
And unfortunately, there’s another catch.
Your Appeal Needs to Be Your Legal Foundation
When your ERISA appeal is reviewed by a federal judge, the judge can only look at what you submitted as part of your appeal. You won’t be able to add any new evidence or redraft your appeal letter. Your appeal is your one shot at getting your short-term disability benefits.
This is why you need to speak with a lawyer who knows how ERISA claims work and how to craft the most effective appeal possible. Experienced ERISA attorneys know that they need to treat the initial appeal as a legal foundation just in case it’s reviewed by a federal judge.
And, you guessed it, there’s yet another catch.
Difficult Legal Standard If the Case Goes Before a Federal Judge
In ERISA cases, the denial can only be overruled if the appeal meets the abuse of discretion standard. This means that the appeal must show that the insurer acted unreasonably or arbitrarily when they denied your benefits.
This is an extremely difficult legal standard to meet. Even if the rest of your appeal has merit and the evidence is clear and persuasive, you will not get your benefits if the appeal does not meet the abuse of discretion standard.
Why Choose Sinclair Law Firm After Your Claim Is Denied
Many law firms in the Birmingham area can help after your disability claim has been denied. However, few firms offer the same level of attention and experience as we do, especially when dealing with ERISA.
Here are a few reasons why people come to Sinclair Law Firm after their disability benefits have been denied.
- We Know How Insurers Operate: Tom started his legal career representing automakers and insurance companies. He realized his true calling involved helping working people who were failed by the system. Tom can use his experience to identify the tactics used against you and craft a strong appeal.
- We’re a Known-Quantity to Insurance Companies: We’ve heard that insurance companies will flag Tom’s name if it comes up in a file. That delights us to no end. To our team, that means we’ve been doing right by the people of Alabama, and insurers know we will fight tirelessly for our clients.
- We Work with Our Own Experts: Insurance companies have a team of experts that will dispute and deny your claim. Sinclair Law Firm works with its own team of experts to provide supporting evidence and build a strong legal foundation in your appeal.
- We Provide Free Claim Reviews: If you’re injured and unable to work, times are tight. Tom provides free, no-obligation, and confidential claim reviews so you can get answers to your questions and receive reliable guidance without worrying about another bill.
- We Will Work Within Your Financial Situation: Being out of work and without income for just a short period of time can turn your life upside down. Our team understands this, which is why we will discuss your financial situation and figure out a payment plan that’s fair and makes sense for you.
Was Your Short-Term Disability Denied? Request a Free Claim Review
Don’t delay if you’ve been denied short-term disability. Sinclair Law Firm can help you receive the benefits you’ve earned but have been denied. Let’s level the playing field for you. For a free claim review, contact our Alabama law firm today. You can also request a free consultation by phone at (877) 249-0091.