1. Figure out why you were denied?
Your insurance company owes you a fiduciary duty. A fiduciary duty is an obligation to act in a certain way toward a certain group of people. In the ERISA disability context, the plan administrator owes a fiduciary duty to all of the plan beneficiaries. You are a plan beneficiary.
That means you can ask your plan administrator, or any person acting for your plan administrator, why he or she denied your claim and they have to answer you. The insurance company is obligated to detail why they denied your claim. You need to know this before you draft your appeal document so that you know what was important to the insurance company. Now you can correct any misunderstandings that the insurance company has about you.
2. Figure out your deadlines.
Deadlines are crucial. If you miss a deadline, then your case is essentially over. You have to figure out when all of these deadlines are and put them on a calendar. We’ll leave it at that.
3. Gather all of the right information.
If you don’t have the right information to present to the insurance company on your insurance denial appeal, you will lose. Just because you submit mounds of information to the insurance company doesn’t mean you submitted all of the right information. You have to cover all of your bases to make sure the insurance company will have a reason to change their denial. Beyond that, you have to make sure that the insurance company cannot find any reason to further deny the benefits you are entitled to.
Because you did step one, you already know what is important to the insurance company and you can address it. You need to gather expert opinions and medical records that support your disability and challenge the reasons why the insurance company denied your claim. You need to address every single issue the insurance company cited in its denial or any later explanation of the denial. This requires a detailed review of the denial letters and a detailed review of all of your medical records.
Often, when a patient leaves the doctors office, what the doctor says and then writes down in the record are two different things. More often, the electronic medical record system has prefilled spots that the doctor doesn’t check, or uncheck, that creates some confusion in what the doctor’s opinion truly is. If there are some inconsistencies in the medical records, you need to find them and then ask your doctor for a written clarification of that issue to present to the insurance company.
4. Put it all together in a persuasive appeal.
The last thing you have to do is write a persuasive and comprehensive appeal letter. Depending on the nature of your disability and the number of providers you’ve seen, your letter will vary in length. However, it is not unusual for an appeal letter to consist of 20-30 pages worth of information along with numerous exhibits. The appeal has to be structured in a way that covers all of the important issues and leaves no stone unturned. If you lose this insurance appeal, your only recourse is to file suit in federal district court and that court will usually review the insurance company’s decision for an abuse of discretion. When putting together your appeal, the content must be presented in a way that any objective observer would feel like the insurance company’s denial was an abuse of discretion. You may ask, “what does ‘abuse of discrection’ actually mean?” Well, the 4th Circuit Court of Appeals described it here:
Where an ERISA administrator rejects a claim to benefits on the strength of substantial evidence, careful and coherent reasoning, faithful adherence to the letter of ERISA and the language in the plan, and a fair and searching process, there can be no abuse of discretion . . . .
Evans v. Eaton Corp. Long Term Disability Plan, 514 F.3d 315, 325-26 (4th Cir. 2008). In other words, getting your insurance company’s denial reversed in court will be difficult, unless you present the case in the best possible light.