Have you properly prepared your claim in case you have to file suit against your disability insurance Company? The answer may surprise you. Group disability insurance lawsuits are not typical trials. Most group disability insurance plans that you receive from your employer fall under the Employee Retirement Income Security Act of 1974 (“ERISA”). If you have been denied disability insurance benefits under an ERISA governed policy, you MUST first appeal the denial directly to your insurance company and follow the carriers mandatory appeals process. If the denial is upheld, you have a right to file a lawsuit. Typically, your lawsuit will be filed in federal court. Usually, your entire case will be based on the information gathered during the application and administrative appeal stage. All other information not previously submitted will most likely not be considered at trial. You will not have a jury of your peers decide the case, but rather a federal judge.
Thus, you actually prepare a significant portion of your trial during the administrative appeal stage. Under most circumstances, if you fail to provide any relevant information prior to or with the appeal and the insurance company upholds its denial of benefits, you will be forever barred from bring forth the new evidence at trial. Thus, in most cases, it is essential that you prepare your trial in the six months that you have to appeal your insurance carrier’s denial of benefits.
Many claimant’s, unaware of this fact, merely submit a letter from their treating physician disputing the disability insurance carrier’s determination or simply provide updated medical records. In so doing, many truly disabled individuals severely damage their claims for benefits. Most people would be weary of preparing their own trial without the assistance of an attorney and of basing their entire lawsuit on the meager evidence described above. While under certain circumstances the administrative record can be re-opened, allowing additional information in, it is essential that you understand the possible damage that can be done to your claim by failing to prepare an effective and thorough appeal of an ERISA governed disability insurance claim. Insurance companies often have “independent” medical reviewers provide an opinion of your documentation or a vocational expert prepare a report assessing whether you are capable of working in some capacity. It may be important to counter this information with a truly independent physician review, an independent medical examination, and/or a vocational expert opinion. At trial, you would normally call witnesses to testify regarding your condition, including your co-workers, family members, friends, and your treating physicians. If this is not done prior to or with the appeal, this information will probably never come into your group disability insurance lawsuit.
Moreover, under most circumstances, you not attempting to prove that you are in fact disabled, but that in denying benefits, your insurance carrier acted unreasonably. Essentially, you must prove that the insurance company was not just wrong (and you were disabled), but that given all the evidence, your insurance company could not have come to the adverse determination unless it was clearly acting in its own self interest. Insurance companies will waive their in-house medical review gathered at the appeals stage to assert that while they may have been wrong, there was at least some reasonable support for its decision. This is why submitting the right information during the application and appeals stages is critical to your claim. At Disability Insurance Law Group, we prepare our client’s administrative appeals as if we would be presenting the evidence at trial.