Before you submit an appeal of your group short-term ("STD") or long-term ("LTD") disability claim, it is essential that you understand your obligations and rights under the applicable law. What you do not know, could hurt you!
Most group STD and LTD claims that you receive as a product of your employment, whether you pay the premiums or your employer pays the premiums, are governed by the Employee Retirement Security Act of 1974 ("ERISA"). ERISA is a federal statute that places strict deadlines and requirements on beneficiaries in pursuing a claim for STD or LTD benefits. It is imperative that you meet the strict deadlines in submitting a claim, responding to requests, appealing a denial, or filing a lawsuit, as failure to timely meet these deadlines could be fatal to your claim.
Also, if your claim has been denied, you MUST submit an appeal of the denial to the insurance carrier before you can file a lawsuit. If you skip this step, you will likely be barred from pursing a lawsuit against the insurance company to obtain benefits. Some STD and LTD plans only allow one appeal, some permit claimants to submit a second voluntary appeal if their initial appeal is denied, and others REQUIRE a second mandatory appeal if the denial was upheld after a first appeal is submitted. It is crucial to understand whether your STD or LTD plan requires a second mandatory appeal because, failure to submit a mandatory appeal may preclude you from being able to pursue a lawsuit. An insurance company cannot require you to submit a third appeal before filing a lawsuit.
What you put in your appeal could mean the difference between a claim approval and a claim denial. To best understand what type of information is necessary to provide with your appeal, it is helpful to understand the appeals process and your obligations under ERISA. If the insurance carrier upholds its denial after you submitted all mandatory appeals, you can finally file a lawsuit. However, typically, the only information that the judge (there is not a jury in ERISA governed trials) is information before the insurance company when it made the final adverse determination. That means, the judge will only consider the information you submitted without your application and appeals and all the information gathered by the insurance company when making a decision. Thus, if you leave anything out, the judge will usually not consider it. Your physicians, friends, family members, employers, and co-workers normally will not testify on your behalf. If you did not submit an expert opinion during the administrative appeals process, you likely cannot submit one after. Most people do not understand this and their insurance company never tells them. However, insurance companies do understand the process and thus, usually have in-house medical evaluators or hire medical reviewers to evaluate the claimant's evidence or require the claimant to submit to examinations by medical providers they choose to obtain "expert" opinion reports. Unsurprisingly, very often, these evaluators and examiners make a substantial amount of money to provide these opinions, creating the very real potential for biased reporting.
Once in litigation, under normal circumstances, you have the burden of proof. However, your burden is not to prove that you are disabled under the terms of the plan, it is to prove that the insurance company acted arbitrarily and capriciously when it denied your claim. That means, if there is any reasonable explanation for its decision, you lose. It is an extremely high burden. There is an abundance of cases in which judges render opinions that they believe the claimants are disabled and the insurance companies made the wrong decision, but their decisions were at least reasonable and thus, the claimants lose their cases. Very often, insurance carriers will simply point to their "expert" opinion report or in-person examination report to establish that it had a reasonable basis to deny the claim. Thus, even if claimants submit enough information to establish that they are disabled under the plan, many claims may still be denied if the insurance companies believe that the claimants may not be able to meet their extremely high burden of establishing that the insurance company acted unreasonably in rendering its decision. Thus, it is crucial to submit the right information with your administrative appeal. Preparing your claim as if you are presenting it to a judge, increases the likelihood that you will not have to file a lawsuit.
For this reason, we prepare our clients' appeals as if we are in a trial. Not only do we obtain all necessary medical information, but we interview and obtain "testimony" from our clients and our clients' physicians, friends, family members, and in some cases employers and co-workers. We typically hire medical, psychological, and vocation experts to submit expert opinions regarding our clients' ability to meet the definition of disability found in the policy. We research the insurance companies' in-house and hired evaluators to obtain information regarding their qualifications, past biased reporting, and professional misconduct. We also often obtain detailed responses to the insurance company's hired evaluators' reports from our clients' physicians and independent expert medical evaluators. All of this information is submitted with a comprehensive appeal letter outlining the evidence and the law.
Understanding the process and the law and providing the right information with an STD or LTD appeal could mean the difference between a claim approval and a claim denial. If you prepare your STD or LTD as if you are headed to trial, your chance of never having to initiate a lawsuit increases. Moreover, if your insurance company still fails to do the right thing and pay your claim, you have done the work necessary to place yourself in a good position to meet your high burden in litigation.
Disability Insurance Law Group handles cases at all stages of the STD and LTD disability insurance process, from filing the application for benefits, submitting an appeal of denied benefits, to suing the insurance company for benefits. If you have any questions regarding your STD or LTD claim, please contact us toll free at (866) 363-3628 or via email at [email protected]