ERISA disability insurance appeals are notoriously difficult for claimants to handle on their own. Not only because they are often too sick to manage this complex process, but because the process is littered with challenges and strict requirements which can ensnare a claimant. Most people understand they need an experienced attorney to go to court for any large financial matter, but until they have dealt with a long term disability insurance claim, they may be under the misguided idea that they can do this on their own – or at least until it is time for court – when often it will be too late to find a lawyer who will dedicate the extraordinary amount of time for litigation on a claim where they have not shaped the evidence.
ERISA appeals are governed by a federal law originally designed to protect benefits like pensions and retirement accounts from unscrupulous employers. Over time, long term disability insurance companies came to see that since the long term benefits were part of an employee’s benefits package, these same rules could be used against the policy owner.
These rules include such challenges as:
- The final decision about the appeal is made by the same company issuing the denial- a clear conflict of interest
- Evidence in Federal Court is typically limited to that which is already contained within a claimant’s file.
- The Court often defers its decision to that reached by the insurance company on appeal.
- No trial by jury.
Evidence to be considered for the appeal
Without the guidance of an experienced disability claims attorney, most people don’t know how much material is needed to support a disability claim. A doctor’s note stating the person is disabled and no longer able to able to work will not be enough proof of disability to have a claim accepted.
The amount of information necessary to submit a claim is not the same as that needed for a successful ERISA appeal.
The treating physician needs to be an expert in the field of the disability. This demonstrates a higher level of medical support than that which would be provided by a general practitioner. It also demonstrates the claimant making every effort to seek the right medical treatment for their condition.
The medical record must include every diagnostic test to prove both the medical condition and the severity of the person’s disability. In addition, test results must be performed to demonstrate the impact of the person’s illness or injury on the physical and mental requirements of their occupation.
Newfield Law Group works with leading medical experts in a wide variety of specialties to ensure that our client’s medical records are as thorough as possible and our claim support powerful. We have often been told this attention to detail allows the people reviewing claims to make a decision favorable to our clients, as we have given them all the right information in the right format.
The claimant also needs to have objective proof of the impact of their disability on their ability to perform the material and substantive duties of their occupation. There are tests used to measure the ability to sustain efforts and others to measure cognitive impairments. We draw on our experience with these tests, many of which are considered the gold standard for proving disability, to support our client’s claims.
Only when we have exhausted all possible sources will we submit an ERISA appeal. Once the appeal has been submitted, no additional information will be accepted and/or reviewed. The rules limiting the materials to be submitted are strict. Unlike scenes you see in the movies where someone comes running into a courtroom with new evidence or a new witness, once the ERISA appeal is submitted, there are no additional entries to the claims file.
ERISA Appeal Time Limits Are Set in Stone
Once you’ve received a letter denying your long term disability insurance claim, the clock starts ticking. The letter will include details about why your claim has been denied, including the specific provisions in your policy used to support the denial. There will be directions for how you may file an appeal, including information about where you should send such materials.
Boilerplate legal language in the letter will purport to give you an explanation of how you can file a claim and the time you have to do so. Note that if the insurance company says you may send additional materials to a certain address, those materials are not a response to an appeal. Going back and forth with the insurance company to clarify what materials should be included in an ERISA appeal will cost precious time.
If you do not respond within the deadline for the appeal, you risk permanently losing the ability to fight for your disability insurance benefits.
Your Next Step for an ERISA Disability Appeal? Call Newfield Law Group
If you’ve received a denial letter from your long term disability insurance company, contact our office to discuss your situation. We urge you not to delay, as the time limits are strict and you could lose the ability to appeal your claim.
