When long-term disability benefits get denied, you have an opportunity to file an appeal. It’s best to speak with an attorney as soon as possible to get this process underway. Failing to file an appeal on time means that you’ll lose out on this much-needed income replacement while you’re healing from your injuries. Yet filing an appeal for denied benefits is easier said than done.
The odds are stacked against working people here in Alabama. A big part of that is due to a federal law called ERISA. Attorney Tom Sinclair has helped many Alabamians with ERISA and non-ERISA disability claims over the years. He knows how insurance companies operate and how to create an appeal that increases your chances of securing the disability benefits you were denied.
If you feel that you’ve been wrongly denied disability coverage, Sinclair Law Firm wants to hear from you. We stand up when the system lets people down. To request a free claim review of your denied long-term disability benefits, contact our Birmingham, AL law firm. You can also give us a call 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 long-term disability plans that are subject to ERISA regulations, you will typically have 180 days to submit your appeal.
Consider this denial letter a general set of instructions for your next steps. In addition to deadlines, these letters will often include the reason(s) your claim was denied, instructions on where and how to submit your appeal, and any missing documentation you need.
Why Was My Long-Term Disability Claim Denied?
These are some of the most common reasons people are denied their long-term disability coverage.
- Insufficient Medical Documentation: Insurance companies may claim that your supporting evidence does not show how your injuries affect your ability to work or perform normal daily activities.
- Failure to Meet the Policy’s Definition of “Disability”: Many disability policies have strict definitions as to what constitutes a disability. If your condition doesn’t fit that definition in your policy, your benefits could be denied.
- The Condition Is Not Covered by the Policy: Some disability policies have exclusions that do not cover injuries that are caused by certain activities or that involve factors such as drugs and alcohol.
- An IME Disputes the Disability: Some insurance companies could have an independent medical examiner dispute the severity of your injuries or the cause of your injuries in order to deny a claim.
- Pre-Existing Medical Conditions: If you have a health issue that existed before you received disability coverage, that pre-existing condition could be used to justify a denial of claim.
- Insufficient Work History for Coverage: Long-term disability policies often require a minimum work history to qualify for coverage. If you have not met that minimum work requirement, your benefits can be denied.
- Failure to Follow the Prescribed Treatment Plan: Insurers want claimants to follow a strict treatment plan to help promote recovery. If you miss an appointment or don’t keep records of these visits, your claim could be denied.
- Accusations of Misrepresentation or Fraud: Be careful what you share on social media and other public forums while on disability. Insurance companies monitor what you’re up to and could accuse you of overstating the severity of your injuries or falsifying claims.
- Incomplete or Missing Information: Denials could be issued if there was an error on your part while filling out paperwork and submitting a claim.
- Changes in Your Employment Status: Your long-term disability coverage could be denied if you lost your job, became self-employed, or otherwise changed employment status before you applied for those benefits.
- Errors by the Insurance Company: Claims representatives can sometimes make mistakes. Unfortunately, the policyholder has to file an appeal even if they did nothing wrong.
In addition to the above reasons for denial, you could be asked to pay back your long-term disability benefits due to SSDI or other income. This is a separate issue, but it’s worth consulting an attorney about this matter as well.
How to Appeal a Denied Long-Term Disability Claim
Here’s a brief overview of how to submit an appeal for long-term disability coverage.
- Consider Speaking with a Long-Term Disability Attorney: We recommend speaking with a lawyer as soon as you get that denial letter. The appeal process can be extremely difficult, and an attorney can help you stay on track while avoiding time-consuming and costly setbacks.
- Request Your Full Claim File: It’s your right to receive a copy of your claim file. This will help you see why the insurer decided to deny your claim, including the internal guidelines at the company and the medical evidence that supports their conclusions.
- Compile Supporting Documentation: You will need to gather compelling evidence that counters the reasoning in the claim file. This supporting information might include a letter from your doctor, evidence of medical treatments and visits, updated medical records, and new test results.
- Write a Clear and Compelling Appeal Letter: Among many other things, your appeal letter must address the reason(s) why your claim was denied, with supporting evidence to demonstrate the contrary.
- Make Copies of All Materials and Documents: Make sure to create copies of your appeal letter and all supporting documents before you submit your materials.
- Submit Your Appeal via Certified Mail or Online Portal: When submitting your appeal, use the proper online portal or send the information using a method in which delivery can be confirmed.
Why You Need a Long-Term Disability Appeals Attorney
Filing an appeal for long-term disability benefits is extremely stressful. That stress is compounded when it comes to ERISA claims. Chances are, you haven’t encountered that word or know how it affects disability coverage until your claim has been denied.
ERISA refers to the Employee Retirement Income Security Act of 1974. This is a federal law that applies to all employer-provided benefit plans, possibly including your long-term disability coverage. The law was passed with the best of intentions. Politicians thought that ERISA would protect employees and their benefits. Sadly, insurance companies figured out how to use ERISA against workers, exploiting numerous hurdles in the appeals process in order to avoid paying legitimate claims.
Whether you have an ERISA plan or a non-ERISA policy, it’s in your best interests to contact the team here at Sinclair Law Firm. It’s worth restating: a long-term disability attorney can help you stay on track with your appeal while avoiding time-consuming and costly mistakes.
What Makes the ERISA Appeals Process So Difficult?
The ERISA appeal process is not simple or straightforward. You have a short amount of time to file an appeal, and that appeal needs to be crafted in a specific way. Because of how the process works, this appeal is really your one shot at getting those long-term disability benefits.
You Have a Short Deadline to File an ERISA Appeal
As we mentioned above, you’ll typically have just 180 days to appeal the denial of your ERISA long-term disability benefits. If you do not file your appeal within the 180-day deadline, you forfeit your ability to receive those disability benefits even if you have a rightful claim to them.
Your disability appeal must exhaust administrative remedies. This means the insurance provider reviews your appeal internally at the company, and you can still have your appeal denied.
Once you’ve exhausted administrative remedies, you can take legal action, but that’s not so simple either.
You Cannot File a Bad Faith Claim
Most people assume that they can just sue an insurance company for bad faith when their disability appeal gets denied. Things don’t work that way under ERISA. As a federal law, the ERISA process preempts the state bad faith laws.
Because of ERISA, you cannot sue for damages in a civil case before a jury of your peers. Instead, you can only recover your denied benefits. When your ERISA case goes to court, your appeal is reviewed by a federal judge.
It only gets harder from here.
Your Appeal Is Your Sole Legal Foundation
The federal judge can only review the materials you submitted as part of your appeal. You cannot introduce any new or additional evidence or get a second crack at that appeal letter. If your appeal lacks sufficient supporting documentation and is not persuasive, you won’t receive those benefits.
This is why you need a lawyer who understands how ERISA claims work and how to create an effective appeal. A good ERISA attorney treats the appeal as a legal foundation. They can provide the necessary material as well as compelling supporting evidence that shores up your case when it’s reviewed by a federal judge.
There’s a Difficult Legal Standard If This Goes to a Judge
As you’ve seen, nothing about ERISA is easy. It follows that the legal standard for these cases is also extremely difficult.
The federal judge can only overrule a claim denial if the appeal demonstrates abuse of discretion. This means that the insurer acted arbitrarily or unreasonably when it denied your long-term disability benefits.
If your appeal does not meet the abuse of discretion standard, you will not be able to receive your benefits even if the rest of your documentation is solid.
Why Choose Sinclair Law Firm After Your Benefits Get Denied
This is a hard fight, and you need people on your side who will support you throughout the appeals process.
If you’re searching for a lawyer to help you get the long-term disability benefits you’ve been denied, Tom Sinclair and his team are ready to fight for you. Here are a few reasons why people come to Sinclair Law Firm when they need to appeal a denied disability claim.
- We Know How Insurance Companies Operate: When Tom started his legal career, he represented insurance companies and automakers. He realized his energy was best used to support working people who have been hurt by this system. Tom can identify the tactics insurers use against you and build persuasive and effective appeals.
- We Have a Reputation for Taking on Insurers: When insurance companies notice Tom’s name in a case, they flag that file. That makes all of us here happy. Those insurance companies know that our law firm means business and won’t allow anyone to take advantage of Alabamians.
- We Work with Our Own Experts: Insurance companies have their own set of experts, but so do we. Their experts will deny your benefits, while our experts will help provide supporting evidence and documentation to strengthen your appeal.
- We Offer Free Case Evaluations: Sinclair Law Firm offers free, confidential, and no-obligation claim reviews. We only take on cases when we think we can help. Here’s your opportunity to ask questions and get legal guidance in complicated matters like these.
- We Will Work Within Your Financial Situation: If you’re out of work and recovering from injuries, your budget may be tight. We understand. Our team will discuss your finances and figure out a payment arrangement that is fair and makes sense.
Was Your Long-Term Disability Denied? Request a Free Consultation
If you’re waiting on your long-term disability, Sinclair Law Firm can help make sure you receive the benefits you’ve worked for and earned. We’re on your side. To request a free claim review, contact our Alabama law firm today. You can also ask questions or set up a claim review over the phone at (877) 249-0091.