When your long-term disability insurance has been denied, you almost always have the option to appeal the decision. In nearly every case, the most important first step is to follow the adage, “don’t just do something, sit there!”
We understand the intense pressure to act quickly, but firing off an “I appeal” letter is about the worst thing you can do for your long-term disability claim.
The long-term disability insurance company sure makes it sound easy, though, don’t they? Even as they denied your claim for disability benefits, your claim manager probably told you something along the lines of, “don’t worry about this, it’s easy to appeal, just write us a letter saying you want to appeal, and we will do a new review of your claim.” The disability insurance company may have even “helpfully” included an appeal form with your denial letter. There’s probably a space for you to answer the prompt, “Why are you appealing this denial?” They may give you one whole paragraph’s worth of space to answer!
Don’t fall for it.
Most long-term disability policies give you only one chance to appeal. The next step if your appeal is denied is to file a lawsuit. And here’s the catch: nothing new can be added to your long-term disability claim file once the insurance company has “stopped the clock” by sending you an appeal denial letter. In litigation, the judge usually will not be deciding whether or not you’re disabled – instead, they’ll be deciding whether the disability insurance company’s decision to close your claim was reasonable given the information they had at the time. And when it comes to your claim file, the insurance company always has the last word.
Here's the thing: what you have to say about your long-term disability claim does not matter to the insurance company. You can write the most comprehensive, most heart-wrenching, totally 100% accurate letter explaining point-by-point why the disability benefit denial was a terrible mistake, what your doctors have told you, and why you remain disabled. The long term disability insurance company doesn’t care. To be fair, this is probably not because they are monsters; it’s because their system is not set up to care. Their system is only set up to evaluate what your doctor(s) say about your claim. Your letter may be moving to them, but it’s not evidence. Medical records and physician opinions: that’s the evidence you must provide to win your appeal.
Your appeal is your one chance to add all the evidence you might want a judge to consider if the insurance company denies your long-term disability appeal and refuses to pay your benefits. Make it count.
When you’re staring at a long-term disability denial letter, there are a few steps to take next:
1. Read the denial letter very carefully. You should be able to tell:
- What the policy definition of “Disabled” is, because it changes. In nearly all long-term disability insurance policies, you will be protected for a period of time if you cannot do your own occupation. After that period of time (24 months is most common), you remain protected only if you are unable to work at any reasonable occupation, even a totally sedentary one. Lots of long-term disability claims are denied at this common transition point.
- What medical records the long-term disability insurance company reviewed. Check this list carefully to be sure that the disability insurance company had and reviewed all the medical records that support your claim. Don’t get bogged down in what they say about your records at this point. Just check to make sure that everything important to your claim is included there.
- What your doctors said about your claim. This may tell you exactly what the appeal is going to need to include. If your doctor said that you had no restrictions that would keep you from working, that’s a problem. Every claim has to start with a supportive doctor who will explain to the long term disability insurance company what your restrictions and limitations are, and what evidence they are using as the basis for their opinion (usually test results and the results of your physical exams at your office visits). No doctor support = no disability claim. It’s that important.
- Why the long-term disability insurance company “medical expert(s)” said you could work. Again, don’t get bogged down in why they are wrong and how badly they are misinterpreting your medical records – first, you just need to understand what their point of view is. Did they try to talk to your doctor but your doctor wasn’t available or didn’t respond? Were they unable to determine what evidence your doctor relied on to support their opinion that your condition restricts your activities? Are they dismissing your own reports of how your symptoms impact your ability to work? Fully understanding the disability insurance company’s reasoning is key to showing why it was wrong.
- How long you have to appeal. For most long-term disability claims, you have 180 days from the date you receive the denial letter to file an appeal. If you’re running out of time, here’s the one time you should send a simple, “I appeal” letter! Just send the letter telling the insurance company you are appealing their decision to close your claim, and ask them to “toll the appeal review” until you are able to provide all the information you plan to submit. That will normally buy you some additional time, but work quickly on your appeal steps!
2. Plan your appeal. Based on what you learned in Step 1, make a plan for what you are going to do to counter the long-term disability insurance company’s denial. Be clear about what you are trying to prove. Based on the policy definition of “Disabled,” are you proving that you cannot do your own occupation? Or that you cannot do any occupation, even a sedentary job?
- Do you need to provide additional medical records? Make sure to request those directly from your doctor. (Tip: the “After-Visit Summary” that the doctor hands you at the end of your office visit or that you can download from your portal is NOT the part of the medical record that the insurance company needs. The long term disability insurance company needs to see the complete office visit, which will include sections for things like “examination” and “review of systems.”)
- Does your doctor need to address what the long term disability insurance company’s “medical expert” is saying about your claim? Make sure your doctor has a copy of the denial letter, and point out the sections that talk about both your doctor’s opinion about your condition and the disability insurance company’s medical opinion. Ask your doctor to correct anything the insurance company got wrong about their own opinion and explain why the insurance company’s opinion is wrong. Make sure your doctor knows to explain what evidence they are using to support their opinion. They should also be specific about what your restrictions and limitations are, and why they prevent you from being able to work.
3. Write an appeal letter that connects all the dots. I told you earlier that the long-term disability insurance company doesn’t care what you have to say about your claim, and that’s true. But your appeal letter is the one place you can connect all the dots that explain why you can work. Remember the best writing advice: “show, don’t tell.” Rather than telling the long-term disability insurance company why you are disabled, show them the evidence. Summarize your exam and test results, point out the written support from your doctors, explain why your restrictions and limitations are a mismatch for any jobs that would be reasonable given your training, education, and experience. And remember, with this letter, you’re not just talking to the long-term disability insurance company: you’re potentially talking to the judge who will be evaluating the insurance company’s decision if they deny your appeal.
BenGlassLaw, a leading long-term disability lawyer, can help you.
We will review any letter from any long-term disability insurance company for free. We’ll help you pick out what’s important for your appeal. The good news is that most of the denials we review are appeals you can handle on your own, just by adding additional medical records and/or support from your doctors. If we think you need a lawyer, we’ll tell you. Generally, you might need a lawyer if you’ve read through this article and you’re thinking, “but the long-term disability insurance company has all my medical records, and my doctor support is specific and clear already.” Then we’ll talk about the best next steps for your appeal.