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What do I do if I'm applying for long term disability through my job and the insurance company keeps giving me the run around?

Leominster, MA |

My husband applied for short term disability through his job and is now applying for long term. During receiving short term , the insurance company would take their time approving and sending benefits to him. Even though they had all they needed from doctors they would never approve and send a check until it was time for his next appointment. Now that short term has ended he has applied for long term and they told him this would take 45 days for a decision. Again, they have all the information requested from doctors, and it has been 3 months. They keep sending paperwork asking the same questions or saying they are waiting for information or the nurse has not looked at it. Even his employer has contacted them several times asking why the process is taking so long. What can we do?

Attorney Answers 3

Posted

Not much, unfortunately, other than to keep on sending them what they're asking for. Worse yet, the 45 days they're telling you it will take to make their decision may be just the beginning. ERISA, the federal law that governs benefits like this, says that the insurer has 45 days to make a decision on a claim, but it also says that they can take two 30-day extensions if they want to, and you have no say in the matter. So it may be 105 days (45+30+30) before they make their decision on the LTD.

If you do receive a denial from the LTD carrier, I would urge you and your husband to hire an attorney to help you with the appeal. It can be very, very tempting to try to do these types of appeals on your own. First of all, it's free, and attorneys are not (but we do generally work on contingency fees for these types of cases). Second of all, who understands your medical situation better than you and your doctors? But doing the appeal on your own can be very dangerous, because anytime you're fighting over a benefit you got through work, you're dealing with a federal law called ERISA, as I mentioned before.

One of the weird things about ERISA is that if the LTD carrier doesn't approve the claim, and doesn't approve the appeal, and issues a "final denial," you have a right to take them to Court. That's not weird by itself, but what happens in Court is weird. In court, the record the court reviews is generally closed - i.e., they'll look at the LTD claim file, and probably nothing else. So anything not submitted to them will probably be excluded from the court's consideration. The claimant does not get to testify. The doctors will not get to testify. There will be no jury. It's generally just the LTD claim file, plus arguments from both sides' attorneys, so if there's any good evidence you want to use in the future, you have to make sure it's in their claim file BEFORE the final denial, otherwise you may not be able to use it. That's why you hire an attorney before the final denial - so he or she can help you build that record.

Find a competent employee benefits attorney who understands ERISA and get his or her help on your appeal. There are a lot of good people working on these cases in Mass., but you do not need to limit yourself to your local area. Because ERISA is a federal law, the rules don't change much from place to place, and those of us who work on these cases can often do so from a distance. Also, because there isn't a traditional trial if the case goes to court, attorneys have a little more leeway about where they can practically file the case.

Look around here on Avvo and elsewhere on the web, and find someone you're comfortable with, no matter where they are. ERISA is too complicated to go it alone.

Jeremy Bordelon is a licensed attorney in the State of Tennessee only, and is authorized to practice in all Tennessee State and Federal courts, and before the Social Security Administration in any jurisdiction. The answers provided on Avvo.com are for information purposes only, and should not be relied on as legal advice. This answer does not create an attorney-client relationship between us. In some jurisdictions, this answer may be construed as attorney advertising.

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Posted

While there is nothing they can be forced to do, I find that insurance companies play fewer games with attorneys than they do with my clients. My guess is because they know an attorney such as Mr. Bordelon or myself knows the applicable law and therefore the insurer cannot take advantage of our clients the way they do with unrepresented claimants.

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Posted

Unfortunately this is all too common in the STD/LTD insurance business. They are probably asking for the same information in hopes the doctor puts down something different that could potentially deny him. You could file a complaint with the state insurance commission. Just don't give up. That is what they are hoping you do.

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