When we file our ERISA disability insurance appeals, the process has specified processes and timelines that govern the claim timing and process. However, the ERISA regulations have changed to require insurance companies to provide the “pre-denial” notice and materials, which permit claimants to respond to new evidence or rationales before the appeal is formally denied.
Thus, we are permitted to develop further support and submit additional information and arguments in response to this pre-denial notice. A paralegal once asked me when the disability insurance appeal process is finally completed. My response to her was “When the insurance company cries UNCLE.” We will submit rebuttal after rebuttal, if the insurance company develops additional support during the process, in their undying efforts to deny disability insurance claims.
It’s important to understand the multiple levels of continuing submissions strategically used in the LTD appeals process and how closely we work with our clients and their treating physicians every step of the way. Often, our cases involve handling numerous supplemental submissions on one appeal. Stated, we do not stop until the job is done – and the insurer capitulates.
As a result of this unparalleled level of support and follow-up, we have a loyal group of clients who work with us, as they need us, giving them peace of mind. We recognize the challenges facing our clients and don’t treat them like cases in a file folder. They are real people who entrust us with a great responsibility, and we take it very seriously. I often say we combine a passion for winning our cases with compassion for our clients.
Here’s what we’re up against. ERISA, the federal law controlling the long-term disability claims process for group policies, has a highly reticulated timeframe. There are 45 days for the decision on the appeal to be made, with the potential, which is not always granted, for an extra 45 days for special circumstances.
During this brief timeframe, we are often asked to review the insurance company’s own materials (medical, vocational and internal claim handling), giving us insight into their perspective on the claim, the decision they are considering and the information they have at hand before the determination to pay or not pay the claim will be made. They may toll their time frames while your response is pending, delaying the ultimate adjudication of your claim.
When possible, we take a moderated approach to the professionals assigned to the claim, seeking to educate and enlighten them to see the claim from our client’s perspective. We prepare and submit supplemental submissions to advocate further for our clients. We secure further medical and vocational support as appropriate. Our goal is to overturn the decision, win the appeal, and get our clients paid.
We always have the end in mind: getting our clients paid the benefits they deserve. Avoiding litigation if possible.
The appeal then becomes a back-and-forth process, where we continue to look to undercut whatever further evidence is developed and counter that with our own robust support of the claim. Each time they seek to support or buttress their determination, we swing at the issues to knock them down.
Ultimately, either a decision will be reached, finally rejecting our material, or they will accept our relentless arguments and reinstate our client’s claim.
If this sounds like the kind of personal, focused representation you want for your claim, I encourage you to call our office to have a frank and informative discussion about your situation. There is no fee for a consultation, and there is also no obligation to go forward. It’s a worthwhile use of your time to find out what you’re up against and what you can expect from your insurance company.
