What needs to be included in my LTD appeal (so that it can be submitted properly on my own)?

Asked 6 months ago - Los Angeles, CA

Recently, my Long Term Disability benefits were approved by LM & they paid me for 3 mos. (for my claim - major depression & anxiety based upon the information provided from my family practitioner that I've been seeing for 4 yrs).

After visiting a therapist (one time) & she submitted documentation to LM, LM abruptly denied my claim/benefits and they said that my depression wasn’t severe enough but I was bipolar!

I am very depressed, w/anxiety (chest pains, migraines) & insomnia (also other symptoms). I would like to appeal LM’s decision, but I don’t know what needs to be included.

My mother read that a lot of people who submit their appeals (on their own) are incorrect / insufficient & are immediately denied by insurance companies (especially LM).

Please advise.

Thanks! :)

Attorney answers (3)

  1. Wendy Marie Schenk

    Contributor Level 16

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    Answered . Gotta ask, if you were a doctor or a dentist.,,would you operate on yourself!?! How stupid would that be? So why are you handling this legal matter on your own? Would you operate on your mom, not knowing what you are doing..or would you be scared of screwing up? That's basically what you are doing to your own case, screwing it up. And ur mom giving advice from the sidelines...well, she might as well remove your liver without a medical license with a spoon...u still trust her to guide you? If so, u are stupid. Hire an attorney...someone who is experienced in these matters and can maximize your recovery.

  2. Brad S Kane

    Pro

    Contributor Level 18

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    Answered . Disability appeals are especially difficult. Since you are disabled due to a psychological disorder, it may be particularly difficult for you comply with all the procedural and substantive requirement for the appeal, let alone do it well enought to win. Often the appeal is merely the way to create the administrative record for the appeal to the administrator's decision to a court. You should strongly consider hiring a lawyer to represent you on your appeal. You may also qualify for social security disability benefits and should consider applying for those benefits as well.

  3. Jeremy Lyle Bordelon

    Pro

    Contributor Level 14

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    Lawyers agree

    Answered . 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, as your mother read, because anytime you're fighting over a benefit you got through work, you're dealing with a federal law called ERISA. Most people get their long term disability insurance through work, so I assume you did, too.

    One of the weird things about ERISA is that if LM doesn't approve you, 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 LM's claim file, and probably nothing else. So anything not submitted to LM will probably be excluded from the court's consideration. You will not get to testify. Your doctors will not get to testify. There will be no jury. It's generally just their 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 Southern Cal, 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... more

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