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What is the Disability Insurance Company’s Appeals Process for Long-Term Disability ERISA Claims?

Tuesday, August 25th, 2020

Most claimants are surprised to learn their disability denial battle does not happen in a court room, and there’s no jury. It’s actually worse.

The disability insurance company that denied your claim is the same company you ask to review your claim denial. They determine whether or not your claim is paid or not.

We say it’s putting the fox in charge of the hen house. No offense to foxes or hens.

You read it right: the same company in charge of the denial is also in charge of the review. If your claim is denied, the insurance company’s internal appeals process is the only forum available to you.

If, on appeal, your claim will still be denied, the insurance company will send a preview—a medical review of your file. A medical doctor who is paid by the insurance company, as an employee of the insurance company or an outside contractor, will review your claims documents. The medical report is often based solely on a review of the materials your physician provided the insurance company.

The report is sent to your doctor, asking if they agree or disagree with the evaluation. If the report says you are not disabled, either your doctor has to also be a disability lawyer and start preparing the paperwork to combat the claim, or you need to speak with an attorney immediately.

Disability Insurance is an Employee Benefit, So It Falls Under ERISA

Employee benefits are governed by a law created to protect employees (ERISA) but has been twisted to constrain the process of fighting for disability claims. If a claimant is compelled to bring a lawsuit following the appeals process with the insurance company, generally the only documents that can be reviewed in litigation are those are in your claim file. Because of this, Frankel & Newfield devotes a lot of time to making sure your claim file is built to withstand challenges and to provide the appropriate support and documentation for the record.

Time Limits on Responses Are Critical

The law also constrains the time frame permitted to appeal your claim. Each policy is different, so you’ll need to read your policy, but in most cases, it’s 180 days. And note the time frame is not six months, but precisely 180 days. Lengthy court battles have been fought over whether or not a federal holiday should be counted.

This is the extent to which the disability insurance companies will go to push back on a claim.

If you have filed a claim, be on the look-out for mail concerning your claim. Disability insurance companies hire many different subcontractors, from third party administrators to medical review practices to surveillance companies. Any mail you get could contain time-sensitive information and you must respond in a timely manner to protect your claim. If you are too ill or injured to open mail, someone in your household needs to be put in charge of this task.

There may be requests for information that are not valid—but unless you have the ability to review all of the provisions in your policy and analyze what materials do and do not need to be provided, you may not know it. For example, we have seen cases where decades of personal finance information was requested, having nothing to do with the claimant’s current financial status—but the insurance company demanded it be produced.

If you have received a formal denial or termination letter of your long-term disability claim, contact the law firm of Frankel & Newfield. Our clients are people just like you – at the worst time of their lives, when they need to focus on their health and not take on the stress of dealing with an impersonal and uncaring insurance company.

If you have received a denial letter, the clock has begun ticking on your time to respond. We recommend you call us today, learn how we can help, and start on the steps needed to defend your claim.

Jason A. Newfield

Written By:

Jason A. Newfield - Disability Insurance Attorney

Jason Newfield is a founding partner of the disability insurance law firm Frankel & Newfield. He has spent the majority of his legal career advocating for the rights of disabled workers. He has lectured other professionals, worked on a Federal Advisory committee, and published many articles in the field of disability insurance claims and litigation.

Learn more about Jason | See Jason’s Publications



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This is about a Social Security Disability claim.

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