The decision-making process behind Long-Term Disability (LTD) insurance claims is intricate and, depending upon the size of the benefits, typically involves several layers of review, each of which can significantly impact the outcome. As an experienced attorney, Jason Newfield is skilled with more than the legal requirements and standards that guide these decisions. His two plus decades of experience and knowledge about the business side of long term disability insurance provides him with an edge, as he also knows the strategic aspects needed to help client’s claims navigate the system.
Let’s look at key factors involved in how long term disability insurance claims are decided, including the role of medical reviews, the importance of deadlines, the need to demonstrate “arbitrary and capricious” conduct, or an abuse of discretion, as well as the presence of conflicts of interest and its impact upon the handling of the disability insurance claim, and why the disability claim file is essential in litigation and for your record to be powerful.
Paper-Only Medical Reviews
One of the central elements in the decision-making process for long term disability (LTD) claims is the medical review. However, in many cases, these reviews are conducted on a “paper-only” basis, meaning that the insurance company evaluates your claim based solely on the medical documentation and records you provide. This can include doctors’ reports, medical records, test results, and statements from healthcare providers.
While this process may seem straightforward, it is a double-edged sword. On the one hand, it allows for a relatively quick review of your claim without the need for a face-to-face evaluation. On the other hand, it means that the insurance adjuster is making decisions based on paperwork, and our experience has included many instances when the paperwork is selectively provided, often missing key information. Other times, the paperwork alone doesn’t fully capture the extent of your disability. A document may fail to convey important nuances about your condition or the functional limitations it causes, leaving room for misinterpretation or underappreciation of the severity of your situation.
In these paper-only reviews, the denial often comes down to technicalities such as incomplete or insufficient medical documentation. Insurers may argue that the information provided doesn’t meet the criteria required for approval, even if your disability is legitimate. One of Jason Newfield’s tasks is to ensure your medical records are thorough, comprehensive, and properly submitted to support their claim.
The Importance of Meeting Deadlines
Insurance companies impose strict deadlines for filing claims, submitting additional documentation, and appealing denials. These deadlines are legally binding, and failing to meet them can result in the denial or forfeiture of your benefits, regardless of the merits of your claim. Appeals of ERISA claims must be submitted within 180 days of the decision.
The importance of adhering to deadlines cannot be overstated. In the initial filing phase, most insurance policies will have specific dates by which you must submit a claim. Missing these deadlines can result in an outright denial of your claim. Even after a claim is denied, deadlines for submitting an appeal or requesting an administrative review are critical. Most insurance policies provide a limited time window—often 180 days although sometimes less—for filing an appeal.
Miss these deadlines and you lose the opportunity to present additional evidence or challenge an adverse decision. Jason Newfield makes sure that deadlines are carefully observed and your paperwork is filed in a timely manner.
Jason’s experience with insurance companies also comes into play when it comes to “missing” documents. So many times, claimants file paperwork, only to learn when they call that no one knows where their documents are. The fax “wasn’t received” or the file is on someone else’s desk. This is not like a lost birthday card – the missing document can be the key to your receiving a lifetime of benefits or having to empty savings accounts or sell your home.
What Does Arbitrary and Capricious Conduct Mean to a Disability Claim?
When an insurance company denies a claim, the legal standard of “arbitrary and capricious” conduct often plays a central role in determining whether the denial was justified. This legal standard holds that an insurance company’s decision must not be made in an unreasonable or unjustifiable manner.
If yours is an ERISA claim, that is, your disability policy comes to you as part of your employee benefits package, you don’t have the option of suing the insurance company until you’ve exhausted all administrative claims. This is something that comes as a surprise to most claimants. So, the legal standard of arbitrary and capricious conduct doesn’t come into play until a long battle has taken place.
If you have a privately purchased or Independent LTD policy, this standard will be part of your case. If an insurer denies a claim based on a flimsy or contradictory rationale, or if they fail to provide adequate reasoning for their decision, the denial may be challenged under this standard.
Jason Newfield has represented clients with private policies when their claims were denied despite robust medical records and treating physician’s opinions. If the insurer disregards or selectively interprets the evidence, their actions may be deemed arbitrary and capricious. Showing that an insurance company acted arbitrarily and capriciously can be challenging without the benefit of skilled legal representation.
Newfield Law Group investigates whether or not the insurer followed proper procedures, considered all relevant evidence, and provided a reasonable explanation for the denial. Demonstrating arbitrary and capricious behavior may be essential in securing a favorable outcome in litigation or appeal.
The Inherent Conflict of Interest in Long Term Disability Claims
This one is obvious to anyone. The same insurance company responsible for making payments on your claim is also responsible for approving or denying claims. This creates a situation where the insurer has a vested financial interest in denying or limiting claims to minimize their payout obligations.
This conflict of interest is a known issue in the long-term disability claims process, with many judges and even State Insurance Commissioners chastising insurance company executives for putting profits over people. Insurance company employees, including medical doctors, nurses and others in the reviewing process are incentivized to minimize payouts by finding reasons to deny claims. Their job security, salaries and bonuses are based on how many claims they deny and how much money they keep in the company’s coffers.
Developing evidence of the impact of the conflict is of paramount significance to success. Federal law requires that when an insurer has a conflict of interest in administering a claim, they must take this into account when making decisions about the claim. Courts often apply a heightened standard of scrutiny to cases where an insurer has such a conflict. For example, if a court finds that an insurance company’s claims adjusters are operating under a conflict of interest, the judge may be more likely to find that the insurer acted arbitrarily and capriciously if the claim is denied. But it’s never that simple.
Why are Appeal Documents so Critical for Court Review?
When an LTD claim is denied, the appeal is an essential tool for challenging that decision. The documents used in the appeal – the “file” – are the only ones admissible to the court if litigation becomes necessary. The record established during the appeals process — particularly the evidence and arguments presented — will be the only material reviewed by a court when determining whether the denial was appropriate.
Jason Newfield has successfully represented many claimants who needed to appeal their denial. He understands what it takes to create a well-documented and robust file to withstand the challenges of the appeal and be ready for litigation.
The strength of the appeal directly impacts the potential outcome of any future litigation. A poorly constructed appeal could severely limit your chances of prevailing in court. Therefore, working with Jason Newfield, who understands the strategic importance of a comprehensive appeal is essential for maximizing your chances of success.
With the right legal representation and careful attention to the details of the claims process, claimants can ensure that they have the best possible chance of securing the benefits they rightfully deserve.
If you have questions about your LTD claim, we invite you to contact the office for a free consultation with Disability Attorney Jason Newfield.
