Appeal your Long-Term ERISA Disability Denial-The 5 Steps Insurance Companies Hope You Don't Know
Your employer’s insurance company (UNUM, Aetna, Hartford, Standard, Prudential, etc.) denied your claim for long-term disability benefits. Now what?' Assuming you are not represented by an attorney, if this is your first denial for long-term disability benefits, here's what you need to do now.
Call for back up.Obtain knowledgeable and experienced legal assistance. ERISA long-term disability cases are complex and will possibly end up with you in federal court. Most attorneys who handle these claims will do so on a contingency fee basis. Find one. You have enough to worry about with your physical and/or mental limitations. Let this burden be your attorney's. Listen to his or her advice; it will be invaluable compared to you trying to go this alone. Because your claim may end up in federal court, I do not suggest using a paralegal, friend or relative to represent you. If you want it done right, hire the person who went to law school to provide you with the legal services you deserve.
Put it in writing.If you're sitting there with a denial notice in your hand, you probably now realize that the claims representative you have been speaking to for the insurance company, is not your best friend. The claims representative is loyal to the insurance company, not you. All communication should be professional, polite and preferably in writing by certified mail. This will be crucial proof if your case needs to proceed to federal court.
Know your case.Obtain all your relevant information. Again, the insurance company is not your friend. Has it provided you with a complete copy of your plan? Do you know whether you have been under surveillance? Do you know what the insurance company's doctors have said about your and your impairments. Hint: if you've been denied, the insurance company's doctors are probably reporting that you are faking your impairments or otherwise not credible. Has your doctor submitted all the necessary documentation?
Did you request your file?
If you are unsure or cannot answer these questions, you are already at a disadvantage. See Step #1.
Appeal now.File the appeal. Many courts require you, the former employee, to jump through hoops before you can appeal your case to a federal court. It is referred to as "exhausting your administrative remedies"; and with the amount of paperwork you and doctors must complete, it can truly be exhausting. Your first appeal must go through the same insurance company or plan administrator who denied you, and you must adhere to the deadlines set to appeal your claim. Note that the deadline to file your case in federal court largely depends on your state law regarding the statute of limitations.
Sue them.Your disability benefits may be your only avenue for putting food on your table or a roof over your family's head. The insurance company cares about its profits, not about you. Assuming your case has merit, sue them. You may have several years to file a federal court action against the insurance company and/or your employer, so don't assume all is lost once you have exhausted your administrative remedies. This is the time you tell the insurance company that you will see them in court. Just remember, miss a deadline and you could ruin your appeal.