Your insurance claim has been denied, now what?
Dealing with insurance claims that have been denied can lead to frustration, confusion, and discouragement. The reality is, the appeal process can be complex and leave you feeling overwhelmed. We are here to help.
First, it’s important to understand that if you obtained your short-term or long-term disability policy through your employment, ERISA (the Employee Retirement Income Security Act of 1974), a federal law, likely applies to your claim. What does this mean? It means that you must follow certain procedures when filing for benefits or when appealing a claim denial. If you miss a deadline, you may be foreclosed from pursuing your claim further.
Now that we know that ERISA may apply, let’s look at what steps should be followed:
Identify the Reason for Denial
It’s time to review your denial letter. When the insurance company denies your claim, they must provide you with a detailed reason for their denial. Review the insurance company’s reason for denial so that you understand what will need to be addressed in the appeal.
The letter should also include basic information about how to file an appeal and the deadlines that pertain to your appeal. Claimants typically have 180 days to submit an administrative appeal. Failing to submit your appeal within this deadline will likely result in losing your ability to seek benefits in court.
Very often, insurance companies will misstate information or ignore relevant information. If you review your denial letter and are left with questions, it’s time to contact an experienced attorney to help you understand your rights and obligations.
Now that you know why the claim was denied and when you submit the appeal, it’s time to tackle step two.
Review your Disability Plan Document
It is important to understand the Definition of Disability https://www.youtube.com/watch?v=6x-v8MfSa8Q contained in your policy. In your administrative appeal, you should address why you meet the definition of disability. Also, your treatment providers and experts should consider the definition when preparing forms or statements in support of your disability claim.
The unfortunate truth is that many of the Plan Documents are riddled with legalese and hard-to-follow instructions which leave many people feeling helpless and defeated. It is recommended that you contact a disability lawyer to help you understand your rights and obligations under the policy.
Obtain Your Insurance Company’s Claim File
You have a right to receive a complete copy of your insurance company’s claim file. You MUST ask for the claim file in writing.
Your claim file should include all of the information related to your claim. This includes all internal carrier notes, correspondences regarding your claim, in-house medical reviews, surveillance video or reports, medical evidence, policy documents, and your insurance company’s claim guidelines.
Reviewing the claim file will allow you to know exactly what information the insurance company had when it denied your claim. After reviewing the information included, create a list of documents and information you need to obtain to supplement your file and prove your case.
Very often, insurance companies do not fully comply with their obligation to supply claimants with their full claim files. In fact, carriers often leave out key information necessary to effectively appeal a claim denial. If you believe that the claim file you receive is not complete, contact an attorney to understand your rights.
Preparing Your Administrative Appeal of Your Disability Insurance Claim Denial
It is critical for you to understand that as you prepare documents and information for your administrative appeal, you are ultimately preparing for trial. If the insurance company upholds its claim denial after its review of your appeal and a lawsuit is filed, in many cases the only information the court can review is the information submitted prior to the final denial. This means that if any information relevant to your claim is left out, the court cannot consider it. This includes expert testimony, statements from your treatment providers, and witness statements.
Also, your insurance company will typically hire medical and vocational experts to review your claim evidence. It is essential that you, your medical providers, and sometimes and independent expert respond to any medical or vocational reviews. Understanding this is essential for the preparation of your appeal.
Most individuals would not prepare for trial without an experienced attorney. It is recommended that you seek advice from a disability insurance attorney before preparing your administrative appeal.
Submit Your Appeal
When submitting your appeal to the insurance company, make sure you do so in writing. When crafting your written appeal, explain what supplemental documents you are providing and how they pertain to your claim. Provide a list of all evidence submitted with your appeal. Make sure you send your appeal before the deadline and keep a copy of the letter for your files.
Also, make sure that you have proof of all information submitted. Insurance companies are notorious for claiming that they never received an appeal or certain pieces of evidence.
You will receive another letter from the insurance company approving or denying your claim.
If you receive a denial of your appeal, it’s time to file a lawsuit. The tight deadlines and complex nature of these claims mean that if your administrative appeal was not prepared properly and in anticipation of litigation, you will be at a disadvantage. Bringing on our attorneys to correctly prepare your administrative appeal gives you the advantage of being prepared for litigation and the peace of mind knowing that experienced attorneys are handling the details of your case.
Due to the complicated claims process and strict deadlines, contacting a disability attorney for a free consultation is your next best move. You do not have to go through this process alone. We are here to help. If you have questions regarding your short-term or long-term disability insurance policy or if your claim for benefits has been delayed or denied by your insurance company, contact Disability Insurance Law Group for a free consultation. We aggressively fight to obtain the benefits our clients deserve.