Executive Summary: Waiting can materially reduce a claimant’s options, and disability insurance litigation is a highly specialized area of law that is difficult to navigate without experience in the field.
As a long-term disability insurance attorney with decades of experience, I am not surprised when I receive a phone call or email from someone whose deadline for filing an appeal or responding to an insurance company is only a few days away. Four days. Three days. Sometimes two. Or it is a call after the appeal process has been exhausted and the only challenge left is Federal court litigation.
It is not surprising because disability claims can be overwhelming. People who are sick or injured are often trying to manage medical appointments, treatment, family responsibilities, finances, and the uncertainty of being unable to work. At the same time, they may be receiving letters from an insurance company containing unfamiliar legal and insurance terminology. There is never an indication that a lawyer can assist – certainly not something encouraged by the insurance companies.
What is frustrating is that many of these people could have benefited from legal advice much earlier—either before filing the claim, where an attorney might help to shape the presentation of the claim, or when they first suspected there might be a problem or pushback during the claim process, or at the very least when they received the letter denying or terminating the claim.
Often, by the time a claimant realizes that something has gone wrong, some opportunities may already have been lost.
Your Disability Claim May Be One of Your Largest Financial Assets
People often think of their home, retirement accounts, investment accounts, or business interests as their major financial assets. A long-term disability policy may be worth considerably more. Over time – over a long time – and over many months of benefits. That is why the disability insurance companies seek to limit these recurring benefit claims.
Consider a hypothetical professional who has both an employer-sponsored group disability policy and an individual disability policy purchased privately.
Let’s say the group policy provides $4,500 per month in benefits. That is $54,000 per year before considering taxes or other applicable offsets. Even using a conservative figure of $45,000 per year, 15 years of benefits would represent approximately $675,000.
And let’s add to that the private policy providing $10,000 per month. That is $120,000 per year. Using a conservative annual figure of $100,000, 15 years of benefits would represent approximately $1.5 million.
Together, those hypothetical benefits could represent more than $2 million in potential income replacement.
The financial stakes are enormous.
When viewed this way, obtaining knowledgeable advice early in the process is not necessarily an unnecessary expense. It can be a way of protecting a substantial financial asset.
Why Waiting Until the Last Minute Creates Problems
When someone contacts me with only a few days remaining before an appeal deadline, there may be very little time to do what should have been done carefully.
Obtaining and reviewing the insurance policy or plan documents, understanding the medical history, evaluating the insurer’s stated reasons for denying the claim, obtaining the claim file, identifying evidentiary problems, determining what additional information is needed, and developing an appropriate response takes time.
It is particularly difficult when the claimant has already submitted an appeal without understanding what evidence was needed or what issues the insurer was likely to focus on.
In some cases, an appeal can be supplemented with additional evidence. In others, the procedural posture and governing plan documents may significantly affect what can or should be submitted and when.
Disability Insurance Law Is a Highly Specialized Practice
One of the most important things people misunderstand about disability insurance claims is the assumption that a successful professional should be able to handle the matter alone. The claimant may be a physician, surgeon, attorney, executive, business owner, engineer, accountant, or other highly educated professional. They may have spent decades developing expertise in a demanding field.
They consider it to be a process – complete some forms – get the doctor to say “disabled” and get paid. How wrong they often are – as seen over decades in presenting claims, and seeing denied and terminated claims. The naivety of the process that we have seen – often in our most accomplished medical professionals – is stunning, in how they manage to fall into quicksand that might sink their claims.
But professional success does not necessarily translate into expertise in disability insurance law. The same is true of lawyers who do not regularly practice in this area. We have represented attorneys and insurance executives who thought they could manage this process themselves, only to engage the firm to sort out the problems they created.
Disability insurance law is a niche practice. A lawyer who spends most of their time handling another type of litigation may be an excellent attorney and still not have the experience necessary to identify the issues that can make a significant difference in a disability claim.
A cardiologist does not become a neurologist because a neurological issue happens to arise in a patient. Similarly, an accomplished lawyer does not necessarily become a disability insurance lawyer simply because an insurance dispute appears in their mailbox.
Why You Cannot Simply “Fight Back” Against a Large Insurance Company
Claimants sometimes tell me that they intend to handle the matter themselves because they are accustomed to negotiating, managing complex projects, or advocating for themselves. But an individual claimant is not on equal footing with a large insurance company simply because the claimant is intelligent, successful, or professionally accomplished.
The insurance company has claims personnel who handle disability claims every day. It has established procedures, internal resources, medical consultants, investigators, and lawyers who understand the company’s policies and the applicable legal framework.
The insurer’s employees understand how the claims process works, know what information they are looking for, what language appears in the policy, what documentation is missing, and what issues may affect the claim.
A person can be extraordinarily accomplished and still be at a significant informational disadvantage.
The Importance of Understanding the Governing Policy
A disability claim begins with the policy or plan documents. Definitions matter. Exclusions matter. Limitations matter. The distinction between “own occupation” and “any occupation” can matter enormously. So can provisions concerning mental health limitations, pre-existing conditions, residual disability, offsets, earnings, rehabilitation, and the duration of benefits.
For employer-sponsored disability benefits, federal law may also affect the claim. Many such plans are governed by the Employee Retirement Income Security Act, commonly known as ERISA, although not every disability policy is subject to ERISA.
This is one reason early advice can be so valuable: the strategy should be informed by the policy and governing law before important decisions are made—not after.
Disability Claim Deadlines Can Be Critical
For many employer-sponsored disability plans subject to ERISA, federal regulations establish timeframes for claim determinations and appeals. Those deadlines can be complicated by extensions and by the particular circumstances of the claim.
For example, an initial disability determination generally must be made within a specified period, subject to circumstances that may permit extensions. An adverse benefit determination generally triggers a period in which the claimant may submit an administrative appeal.
For many ERISA disability claims, that appeal period is 180 days from the date the claimant receives the adverse benefit determination, although the precise requirements should always be confirmed against the governing plan documents and applicable law.
Do not assume that every disability policy has the same deadlines.
The Claim File Is More Important Than Many Claimants Realize
When a disability claim has been denied, obtaining and reviewing the claim file can be an important part of evaluating what happened. The file may contain medical records, correspondence, claim notes, statements, reports, surveillance materials where applicable, vocational information, internal assessments, and other documents considered by the insurer.
A claimant may look at the file and see hundreds or thousands of pages. An experienced disability attorney may be looking at something very different.
The attorney is asking themselves these kinds of questions:
- What evidence did the insurer rely upon?
- What evidence did it disregard?
- What definition of disability is being applied?
- Are there factual inconsistencies?
- Are the medical opinions adequately supported?
- What information is missing?
- What issues need to be addressed in an appeal?
- What evidence should be developed before the administrative record is complete?
A Few Days is Never Enough Time
A person may call and say, “I just received the denial letter. My appeal is due next week. Can you help?” The amount of meaningful work that can be accomplished in a few days is obviously different from what can be accomplished over several weeks or months.
An attorney may need to learn the claimant’s occupation, understand the medical condition, review the policy, obtain the claim file, identify the insurer’s arguments, speak with treating physicians, identify additional evidence, and determine how the claim should be presented.
None of that should be done casually when hundreds of thousands or even millions of dollars in potential benefits are at stake.
The Most Important Time to Ask for Help May Be Before the Claim Begins
People often believe they need an attorney only after an insurance company has denied their claim. Obtaining advice before submitting a claim can help a claimant understand the policy and the information that may be important to the claim. Shaping the presentation of the claim can be crucial to success.
Advice may also be useful when the insurer begins requesting extensive information, schedules an examination, questions the claimant’s medical condition, raises an issue concerning the claimant’s occupation, or communicates that it is considering terminating or denying benefits.
What Happens When You Wait Too Long?
Waiting creates serious risks.
You will have less time to obtain medical evidence. You may have already made statements that need to be explained or clarified. You may not have identified important provisions in the policy. You may have missed an opportunity to address an issue before the insurer makes its decision.
And if a deadline has already passed, the problem can become substantially more complicated.
This is why my advice is simple: do not wait until you are out of options to find out what your options are.
A disability claim can represent years of income. It can affect your mortgage, retirement plans, family finances, medical care, and ability to maintain the life you worked to build. The earlier you understand the rules and the issues, the more opportunity there may be to make informed decisions.
The Goal Is Not to Make You Fear the Process
The purpose of getting advice early is not to make every disability claimant believe they need to immediately hire a lawyer. Rather, it is to recognize the reality of the process.
Disability insurance claims are complicated. Insurance companies have substantial experience evaluating them. The governing rules can be highly technical. Deadlines can matter. And the financial consequences of an adverse decision can be significant.
If you are dealing with a disability claim, take the time to understand what your policy requires, what deadlines apply, and what evidence may be important.
And if you are considering whether to seek legal advice, consider doing so before the clock is running down to the final few days.
As a disability insurance attorney, I would much rather speak with someone early—when there is time to evaluate the situation and make a plan—than receive a call when the appeal deadline is tomorrow.
Often, the most valuable legal work happens before there is a lawsuit, before there is an appeal, and before the available time has nearly run out.
