ERISA Disability Insurance Claim Appeals

What to Do When Your Disability Claim is Denied

A claimant’s chance of success fighting a big disability insurance company that has denied a claim are typically not great. These huge companies have legal departments, teams of medical experts and outside law firms who do everything they can to deny your claim and fight back against your ERISA appeal. But you don’t have to do this alone. Frankel & Newfield can help you throughout the process of applying for long term disability insurance benefits and fighting back if the disability company denies your claim. Filing an ERISA appeal on your behalf is an area of practice at Frankel & Newfield.

If your disability insurance policy was purchased through your employee’s benefit program – and has been paid by deductions from your paycheck – then your claim is likely governed by a federal law known as ERISA. The disability insurance companies use this law and its limitations to intimidate claimants. And create a challenging hurdle to succeed. The process of appealing a disability insurance claim denial or termination under ERISA is complex and the time limits make it even harder, but Frankel & Newfield has represented many clients in this process. We know what needs to be done and how to succeed in this process, which hopefully will allow you to avoid litigation.

Here’s what one client had to say:

My insurance had actually cut me off, because my Dr. had checked the wrong box – they didn’t call, ask questions, verify, etc. after years of my condition and the medical form always being the same. I have a chronic issue that will not go away or get better.

Instead they cut off my income that day – with no notice. All of a sudden I had no income – and had no idea how to appeal their decision. I thank God I found Jason as he walked me through all of the steps to maximize my supporting information, records etc. that would be needed to send in. Then he added his special legal input and documentation – and after a year of fighting them, my benefits were restored – AND I was provided the back pay!!!

Read the complete testimonial here.

The first step for is for you to contact Frankel & Newfield so we can provide a free evaluation of your case. Call our office today at 877-583-2524 to get started.

Why Is an ERISA Disability Appeal so Challenging?

ERISA is a federal law originally designed to protect employees’ pensions. ERISA law and the regulations law were adopted by disability insurance companies and are used to gain control of the appeals and litigation process when disability claims are denied.

The first step in battling a disability denial is the mandatory Administrative Appeal. You cannot pursue litigation (go to Court) until you have exhausted your administrative remedies (completed the appeal process).

Read A Recent Success Story

In litigation, very often the procedures utilized by the courts when deciding ERISA disability litigation deviate substantially from what we think of as typical lawsuits, often to the detriment of claimants.

If your disability claim is governed by ERISA, it’s an uphill battle. Court is extremely challenging.

Here are just a few of the reasons why:

  • You will not have a trial by jury (only a Federal Judge will decide your case)
  • (Generally) Only the materials in your insurance file can be considered (the Administrative Record)
  • If you miss any deadlines, you may lose the ability to ever get disability benefits.

We have you protected

Read a Recent Success Story

Courts often will provide deference to the decision from the insurance company- which makes the effort to succeed further challenging.
Courts often will not permit discovery to address the significant financial conflict of interest by the insurance company – thus not allowing the claimant to show the significant bias in the process. Courts often do not permit discovery into the doctors who work on behalf of the insurance companies on a repeat basis (Getting their “bread buttered” by the insurance companies).

A dentist who became disabled wrote about Justin Frankel:

He got my claim approved, and now I can start putting my life back together again! Thank you Justin for all of your hard work, dedication, and compassion! If any professionals become disabled, and need to utilize their long term disability benefits, I would only recommend going to Justin Frankel Esq !!!

An ERISA Disability Success Story

A 47 year old woman who had been treated for breast cancer was suffering from the after-effects of chemotherapy. She was a successful neurosurgeon, one of the most challenging medical specialties and one that requires extensive training: her residency training was seven years. She had a group and a private disability policy from The Standard, which initially paid and then terminated her claims. The Standard relied on an outdated database of occupations that did not accurately reflect the duties and tasks of her challenging occupation. Our powerful appeal, which included a strong vocational report, was successful in overcoming the denials. She is now being paid for both policies. Read the complete story here.

Why Is An ERISA Appeal Critical?

Your most important step following a denial or termination of a disability insurance claim governed under ERISA, is to develop an appeal of the denial or termination. Without a thorough understanding of what you are facing, and the potential implications of not thoroughly developing your appeal, that’s not something an inexperienced person – even an attorney who doesn’t work in this area – can do.

Your appeal to the insurance company has to serve two purposes. And it potentially has two separate audiences. One is to fight back against the denial or termination, by submitting the appeal to the insurance company, hoping they recognize the errors and resolve the appeal favorably.

The second is to be ready for what happens if your appeal does not succeed. All of the materials in your Administrative Appeal have to work for a second potential audience – the Federal Judge who may ultimately decide whether or not you are entitled to these precious benefits.

Your appeal must be well developed – and address ALL of the issues which the insurance company has used for its decision. Remember, it’s not just that you are disabled. You must demonstrate how and why you are unable to work.

The appeal materials must address the tasks and duties of your occupation, which are often deliberately misconstrued by the disability insurance company. They must also demonstrate that you are under the continuing care and treatment of a physician that is appropriate to your disability. There are many other factors that go into a disability appeal which need to be aggressively presented both in the Administrative Appeal process and, if necessary, before a Federal Judge.

How Is an ERISA Appeal Developed?

To effectively develop your appeal in response to the denial or termination of your short-term or long-term disability insurance claim, you must consider every aspect of the decision, including the medical consideration of your evidence and materials and the vocational considerations of your ability to work or your impairment from working. You must analyze the claim handling to appreciate what occurred.

We view the insurance company decision as the foundation of a house – to succeed, we try to make the house crumble, taking away each foundation piece.

This is accomplished through our constantly evolving formula for success – which utilizes various tools, resources and strategies to effectively advocate your appeal, and develop the record to enable litigation success if necessary.

Rules Governing ERISA Disability Appeals Are Strict

The rules for an ERISA disability appeal are extremely strict, with defined time frames. Your group disability insurance plan will state whether or not you are permitted to file one or two appeals. Most only permit one level of appeal, and then close the administrative record. Others require two levels prior to litigation.

The information submitted in an ERISA Disability Appeal is extremely important, as all of the documents submitted become part of what is known as the "Administrative Record." Following the decision on appeal, and the “exhaustion” of administrative remedies, a claimant will then be permitted to file a lawsuit against the insurance company.

Why Won’t My ERISA Appeal Be Heard Before a Jury?

ERISA disability appeals do not permit jury trials, so a lawsuit will be decided by a judge. This puts your fate in the hands of one person. The large number of ERISA appeals that our office handles gives us the experience in front of these judges so we know, in most cases, the audience who will be reviewing your materials and considering your future.

Here’s another thing you need to know - the standard to be applied by the Court may vary. That’s why it’s SO important that your appeal be prepared with an aggressive, pro-active and comprehensive approach.

In the event that your ERISA disability appeal is denied, and a lawsuit is filed, the court in most cases will limit their review to the documents in the “claim file.” These will be the ONLY documents that can be reviewed during a Federal Court review of an administrative appeal.

This is why the appeal is the most critical time of the claim. If documents are not part of the record, PRIOR to litigation, most often they will not be considered in court by a Judge.

We Prepare Strong and Persuasive ERISA Disability Appeals

In order to present a powerful and persuasive ERISA disability appeal, we work closely with our clients and their treating physicians, and often other experts, to ensure that the information developed for the appeal contains great detail and a strong articulation as to the severity and degree of impairment and the impact upon our client's functionality.

We work to rebut the medical opinion offered by the insurance company or its hired doctor – using our doctors’ evidence and other collateral evidence and materials to argue why reliance upon these reports is improper.

We also develop strong support for the vocational issues, focusing upon how and why our client cannot engage in work, or cannot perform the duties of either their own occupation, or any occupation, as that term may be defined in the policy, and may differ based upon insurance company. We work to rebut the vocational evidence developed by the insurance company supporting their claim determination.

Read our related blog post - Top Five Things You Need to Know About Filing an ERISA Long Term Disability

The ERISA Disability Administrative Appeals Process Is Not Fair

In our view, the ERISA process is stacked against the claimant. Courts reviewing ERISA disability lawsuits often act as a rubber stamp of the claim termination or denial. Often times, despite evidence of impairment, a court can find “some reason” to uphold the decision.

The appeal is the only opportunity to create a record for litigation with the hope that the Federal court will be receptive to the demonstration of wrongful conduct by the insurer and the powerful medical support for the claim.

Another unsolicited testimonial:

When you and Justin called me yesterday with the great news that we had won the appeal, it felt like a giant weight was lifted off of our shoulders. We can now start to put our lives back together thanks to the amazing work you guys did putting together a great appeal on our behalf. Thank you so, so much!

Read more of what our clients have to say.

Why You Want to Work with Frankel & Newfield

Lawyers who do not practice in this specific area of the law are not familiar with the restrictions. The ERISA disability appeals process is a significant part of the firm's long-term disability insurance practice. We continue to refine our best practices as the case law continues to evolve. Read more about our ERISA Disability Appeals success stories.

There are additional considerations when submitting an ERISA disability appeal outlined here.

Private or Individual Long-Term Disability Insurance is Different than ERISA Disability Insurance
If you have purchased disability insurance through an insurance agent on your own, perhaps as a supplement to the disability insurance that you receive as part of a benefits package, then your policy is likely not subject to the same ERISA disability appeals process. You are able to pursue your claim through a more straightforward process.

These policies are more often purchased by high income individuals who need to ensure their specific occupation. They buy what is known as an “own occupation” policy. For example, a neurosurgeon would buy a disability insurance policy to protect her ability to practice neurosurgery.

These types of private or individual disability insurance policies are subject to strict underwriting processes and they can be fought without the restrictions of ERISA.

Current Political Climate Does Not Favor ERISA Disability Claimants

A pro-business administration in Washington combined with a powerful insurance lobby means there are no soft-landing places for disability claimants. If your disability claim is denied or you are concerned about filing a claim, we encourage you to contact our ERISA disability law firm at 877-583-2524 to learn how our firm can help protect your claim and your family.

We continue to warn claimants be very careful about what they post on social media, as a key government agency has now joined with insurance companies in examining social media posts to gather evidence to challenge claims. You may have one good day a month, but if that good day is posted on social media by you or a friend, your ERISA disability claim could be at risk.

Frankel & Newfield Fights for Claimants Whose ERISA Disability Appeals are Denied

Because of our experience in this area of law, we represent clients throughout the country from our office in New York. Call us at 877-583-2524 or email us to set up a free consultation.

Jason A. Newfield

Written By:

Jason A. Newfield

Disability Insurance Attorney