If you have paid for disability insurance for years, you should be entitled to long-term disability benefits when you need them. Unfortunately, your insurance company’s priority is profits, not people. The insurance system is designed to avoid paying out benefits whenever possible.

A denied disability claim can have a devastating financial impact if you’re unable to work due to a chronic medical condition. The good news is that even if your disability claim is denied, you have the right to appeal.

To help you get started, we’ve outlined some steps on how to appeal a long-term disability denial.

Keep in mind the appeal process heavily favors the insurance company. We strongly recommend consulting a long-term disability lawyer to provide expert guidance and handle the complex legal details for you. Reach out anytime to our compassionate team of disability experts for help with your appeal.

Here’s what we’ll cover:

The Importance of Acting Quickly

As soon as you receive a denial notice from your insurance company, you must act quickly.

Procrastination can lead to unnecessary stress and may jeopardize your appeal.

The appeal process can be lengthy and complicated, especially appeals involving ERISA claims. There are strict deadlines and no second chances. Preparing early will give you a better chance of meeting all deadlines and building a solid case to support your claim.

How to Appeal a Long-Term Disability Denial

1. Understand why you were denied

Start by carefully reviewing the denial letter you received. This letter contains vital information about why your claim was denied and what options are available to you. Understanding the reasons for the denial is key to preparing a successful appeal.

A few common reasons for denial include:

  • Failure to meet the policy’s definition of disability
  • Insufficient or inaccurate medical documentation
  • Missed deadlines

The ERISA appeal process, in particular, has strict regulations and timelines you must adhere to. Pay attention to the specific steps for the appeal process outlined in your denial letter.

After reviewing your denial letter, make a list of issues that you disagree with and that you can support with evidence.

Read more: Why Long-Term Disability Claims are Denied

2. Request your claim file

You must request your claim file from your insurance company before preparing an appeal. Your claim file contains all the documentation and correspondence related to your disability claim, including the insurance company’s notes and decisions.

By reviewing your claim file, you can identify any discrepancies or missing information that may have contributed to the denial, allowing you to build a stronger case for your appeal.

A few tips to keep in mind when you request your claim file:

  • Send your request directly to your disability insurance company
  • Include any claims number(s) and copy any claims examiner(s) listed on your denial letter
  • Request your claim file via certified mail or fax so you have proof of delivery
  • Keep a record of your requests, including how and when you sent them

Important: If your policy is governed by ERISA, your administrative appeal will be your last opportunity to add to your claim file. If your case goes to court, you will only be allowed to show the judge the information in the file.

3. Familiarize yourself with your disability policy

Review your long-term disability policy carefully to understand the criteria in your plan, including pre-existing conditions and any specific exclusions or limitations that may apply.

Your policy will also outline the definition of disability, which will vary between plans and providers. Failure to meet the policy’s definition of disability is one of the most common reasons for a denied claim, so it’s crucial to understand these terms.

Not sure where to find your policy documents? If your current or former employer sponsors your insurance plan, contact your Human Resources representative. If you purchased your insurance policy independently, you can contact the insurance agent or insurance company directly.

4. Start organizing supporting evidence immediately

Once you have a clear understanding of your denial letter and policy details, it’s time to prepare your administrative appeal. You must provide substantial medical evidence to back your claim.

Medical evidence that could be helpful:

  • Any relevant medical records that were not submitted in your original claim (this includes any doctor you have seen for the condition that you are claiming)
  • Any and all supporting medical tests, exams, screenings, appointments, etc.
  • Personal statements from friends and family about your condition’s impact on your daily life
  • Written opinions from your doctor and other medical professionals
  • Employment records that demonstrate how your condition has affected you at work (e.g. annual reviews, accommodations, citations, awards, letters, and anything else that might be related to how your condition has impacted your work)

It’s possible your insurance company may have misinterpreted a doctor’s opinion, as we saw in the case of Noone v. Mutual of Omaha. In that case, Roy Law Group proved that Mutual of Omaha incorrectly stated the outcome of a Functional Capacity Evaluation (FCE) for our client, Maura Noone.

If you find that your medical documentation is insufficient or unclear, act swiftly to get clarification from your healthcare providers.

5. Write a formal appeal letter

Now that you understand why your claim was denied, what evidence is missing, and how to appeal, it’s time to write a formal appeal letter.

Some tips to remember for your appeal letter:

  • Keep it clean and concise
  • State your intent to appeal
  • Include your policy number and the date of the denial notice
  • Address the reasons for denial given in the denial letter and carefully refute each one
  • Request reconsideration of this decision
  • Express your commitment to follow through with the necessary procedures to secure your benefits

Get more details on how to write a formal appeal letter.

The appeal process can be overwhelming, but having an experienced long-term disability lawyer who specializes in ERISA law can make a world of difference. An attorney can collect evidence, coordinate with medical providers, and negotiate with insurance companies on your behalf.

A long-term disability lawyer will also ensure all paperwork is filed correctly and on time. A missed appeal deadline can sabotage your claim, but a lawyer can help to avoid any costly mistakes. If your claim is denied again, your lawyer can help you explore additional options, including litigation if necessary.

By having someone who knows the ins and outs of the law, you can focus on your health and recovery while they handle the complex details. The right attorney can be your strongest ally in your fight for your long-term disability benefits.

Get the benefits you deserve

Remember, a denied disability claim is not the end of the road. With the right approach and persistence, you can increase your chances of a successful appeal.

If you find yourself facing a denied claim, don’t hesitate to reach out to Roy Law Group for expert guidance and support in navigating the complex appeal process. Disability law is all we do. We fight insurance companies every day, and we know what it takes to win.

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