ERISA Long-term disability appeals are difficult. Generally, no new evidence or legal arguments are permitted in federal court. We want you to know all the nuances of ERISA issues so you can make good decisions about your case.
When reviewing a plan administrator’s decision, even “under a deferential standard. The district court is limited to the evidence that was before the plan administrator at the time of the decision.Rust v. Elec. Workers Local No. 26 Pension Trust Fund., No. 3:10-CV-00029, 2011 WL 4565501, at *16 (W.D. Va. Sept. 29, 2011)
In our view, having your appeal handled by an experienced ERISA long-term disability attorney is absolutely critical.
Several respected federal judges have agreed:
In the Court’s experience, [inexperienced] lawyers for ERISA claimants all too often do not appreciate the importance of getting all their evidence in the administrative record. Thus, it is not uncommon for ERISA claimants, when they get to court, to discover they cannot use what they think is critical evidence.Acree v. Hartford Life and Accident Ins. Co., 917 F. Supp. 2d 1296 (M.D.G.A. 2013)
Having recognized the difficulties posed by Plaintiff’s position [of having little to no evidence in the file], the Court also recognizes that ERISA claimants may not have the advantage of legal advice or favorable referrals before the administrative process is complete, placing such claimants at a distinct disadvantage if discovery is not permitted on judicial review. Fore ERISA claimants not able or aware enough to hire legal counsel before the administrative process is complete, they likely enter into judicial review facing a loaded deck—a deck loaded with the expert opinions of those hired by the plan administrator.Abromitis v. Cont’l Cas. Co./CNA Ins. Companies, 261 F. Supp. 2d 388 (W.D.N.C. 2003)
A pro se (“do it yourself”) claimant will be hopelessly outclassed [in an appeal to the disability insurance company] and will [likely] hit a brick wall each time.May v. AT&T Integrated Disability, 948 F. Supp. 2d 1302 (N.D.Ala 2013)
Our goal is to help you understand what your case is about and how you can prevail. Read this information and watch these videos to learn all about ERISA Long-Term Disability cases.
What is an ERISA Disability Appeal?
Brandon Osterbind of Osterbind Law gives a definition of an ERISA Long-term disability appeal. An ERISA Long-term disability appeal is the process of trying to change your insurance company’s mind about your long-term disability claim after they have denied it. You must gather all of the evidence that supports your claim, fill out all necessary paperwork, get doctors to vouch for your claim, etc. If you don’t have the right information, you’ll simply be denied again. If you cannot get the insurance company to change their decision about your claim, you can take them to court and let the judge decide whether or not you qualify for long-term disability based on the evidence and information that you’ve provided.
Why is an ERISA Disability Appeal So Hard?
Why is it so hard to put together an ERISA Long-term disability appeal? Because there’s so much paperwork involved. An ERISA Long-term disability appeal requires information such as medical reports, vocational reports, educational records and reports, testimonies and questionnaires from medical experts and more. The necessary paperwork can add up to hundreds of pages of detailed, expert information. Also, this information will need to be gathered and organized in such a way as to be accurate, complete, logical and persuasive. There are time limits and deadlines for this appeals process, and if you don’t get the necessary information collected and turned in on time, you could lose the ability to appeal your disability case forever.
Should I hire an attorney for my ERISA Disability Appeal?
Why hire an attorney to help with your ERISA Long-term disability appeal process? Because if you’ve been denied disability by your insurance company, it means that they have likely already consulted with attorneys and medical experts who are on their side about your claim. They will have obtained professional opinions on your information and disability claim that invalidate it and provide a basis for the denial.
The point of the ERISA Long-term disability appeal is to level the playing field and get expert opinions on your side in order to change the insurance company’s mind about your disability claim. This is where hiring an attorney comes into play. Your attorney will look at your claim and all the information and reports that you’ve gathered to determine what information you have—and more importantly, what information you don’t have and need to obtain in order to have a successful appeal.
How does an ERISA Disability Appeal Process work?
The ERISA Long-term disability appeal process begins with the attorney sending a letter to your insurance company requesting all of the information about the disability claim and their reasons for denying it. The attorney will then analyze the information in order to attempt to disprove or challenge the information on which the insurance company was relying.
From there, you and the attorney must produce the correct evidence and information to substantiate your claim to disability. All of the information you gather must be put into a legal document called an appeal letter that explains to the insurance company why you should be approved for disability insurance. You have 180 days after your denial to complete this process.
Once the insurance company has the information, they have 45-90 days to reach a decision. If they deny the claim again, you can either take the appeal to the court and present the case to a judge, who will have the authority to say whether or not the insurance company has abused their discretion.
How do I pay for an ERISA long-term disability lawyer?
What does payment look like when hiring a ERISA Long-term disability attorney? Many people can’t afford an attorney when they’ve become disabled, so the attorney will charge a contingency fee. This type of fee means that the attorney will only get paid for their services if they win the disability case. They assume a great deal of risk in the case, and will not be paid if they lose the disability appeal to the insurance company. However, if the appeal is won, the fee can be up to ⅓ of the total earnings.
Attorney fees and costs are different, however. The Virginia Bar requires that your attorney bills you for the costs that they spent on the case, such as obtaining medical records, filing fees with the court, and sitting down with your doctors. These costs can be easily recovered if the case is won, but even if it isn’t, you’ll still be billed for those costs. Osterbind Law of Central Virginia can help with your disability claims and appeals.
Why do insurers deny long-term disability claims?
Why would an insurance company deny a ERISA Long-term disability claim? There are several reasons. The most common reason is that not all of the information required to determine eligibility for disability was provided to the insurance company. Because of that, the insurance company is able to say that the claim cannot be substantiated and has been denied due to the lack of information.
Another reason is that the information you provide to the insurance company isn’t specific enough and doesn’t go into enough detail about your injuries, symptoms, and reasons for not being able to work. The insurance company may also have studied the information provided and picked phrases out of context that suggests that you’re not disabled and that your claim is invalid. The rest of the information, such as medical notes from doctors, may detail your symptoms, but if the insurance company can find something small that indicates that you aren’t disabled, they can use that against you.
The best way to convince the insurance company to approve your claim is to provide a high quantity of specific and accurate information so that they will not be able to deny your claim.
How many times can you file an ERISA long-term disability appeal?
There is usually one appeal opportunity after your insurance company denies your ERISA Long-term disability claim. This appeal is a short period of time (usually about 180 days) in which you have the opportunity to submit more information to substantiate your claim. If your appeal is denied again after this, there may be a mandatory or voluntary secondary appeal opportunity, depending on what is in your insurance contract.
Do what you can to solve the matter with your insurance company, because after a final denial letter, your only other option is to take the case to the federal district court and maybe even beyond, and let a federal judge decide if you meet the terms of disability as listed out in your insurance contract. But your best chance for a successful appeal is at the insurance company level. Osterbind Law can help you with your disability appeal process.
What should I bring with me to my first meeting with an ERISA disability lawyer?
To prepare for an attorney consultation about ERISA Long-term disability denial, you need to collect and bring along some key pieces of information. Make sure you bring the letter from the insurance company about why you were denied, your disability application, policy information from your insurance company and any other medical information you have about the disability.
The attorney will look at all of this information and find out what parts were important to the insurance company in denying your claim, and from there, your attorney can decide if they think you will win or lose this claim. If you don’t bring the right information to your consultation, your attorney will not be able to help you properly and won’t be able to tell if you have a case. Osterbind Law of Central Virginia specializes in wrongful hurt and death cases and much more, and can help you in your disability appeal process.
How long can I get long term disability benefits for a mental illness
How long can you get long-term disability benefits if your disability is based on a mental illness? In most insurance policies, there is a limitation of how long you will qualify for benefits.
Often, this limitation is for 2 years. However, some policies may be different. If you bring us your policy, we’ll tell you exactly how much you are entitled to.
What are my chances of success in my long term disability claim?
Your attorney will give you an opinion about your chances of success. But your chances of winning will be based on the degree of your disability and the information contained in the claim file.
Sometimes, the insurance company has numerous valid doctor opinions that are detrimental to your claim. Other times, they just have an inexperienced career insurance nurse who has never treated a patient. Your chances of success is based on the evidence supporting your disability.
What if I can do some of my job but not all of my job?
The hardest part of being disabled is being able to do some things but not all things. Most ERISA long-term disability insurance policies start with the definition of disability. That definition is different in every policy. But often it is some variation of “the claimant is disabled when he is unable to perform the main duties of his own occupation.”
That has been interpreted by the courts to mean that if you cannot perform a main duty of your own occupation, then you cannot perform the main duties of your own occupation.
What is the best of evidence for your ERISA disability claim?
What is the best way to prove your ERISA long-term disability claim? There are many different ways to prove a disability claim. But in our experience, the absolute best piece of evidence that you can present is objective evidence.
You have to prove that you actually have a medical condition and that you actually cannot work. If your doctor opines that you cannot work but that opinion is not based on objective evidence, the insurance company will be skeptical. Eliminate that skepticism by offering objective evidence.
What if my doctor thinks I can still work?
What if your doctor thinks you can work? That makes your case very, very difficult. Proving your disability comes from several sources of evidence. But the main evidence that you have to submit is medical support. We tell people that without medical support, your chances of winning are very low. And that is painful to hear. Perhaps consider going to a different doctor for a second opinion.
Can’t I just sue my insurance company?
Can you just sue the insurance company for denying your long-term disability claim? The answer is no. In every LTD policy that we’ve ever seen there is an appeal process that that you are required to go through. If you fail to go through the appeal process, then your case will be dismissed in federal court because you failed to exhaust your administrative remedies. So you have to follow through with the appeal process.
How can my friends and family help me get LTD benefits?
Medical records and doctor opinions are important in determining whether you qualify for disability. However, that is not the only evidence that is probative of your physical or mental condition. We always submit affidavits from our clients’ friends and family so that we can explain in layman terms how your condition affects your ability to live life and work. So you friends and family can be helpful, mainly by being observant and being willing to tell your story for you.
The One Line Appeal Letter. Is that a good thing?
What is this one line appeal letter? We’ve had more than one client come to us and say “the claim specialist denied the claim and told me just to send an email noting that I appeal.” That is the one line appeal letter. It is a trick from the insurance company. You have to submit more information that the insurance company did not have before and tell them why they are wrong and how they violated ERISA in denying your claim. The one line appeal letter NEVER WORKS!
How can I embarrass the insurance company on appeal?
What is the best way to embarrass the insurance company in my appeal such that they reverse their decision? This happens all to often. When the insurance company gets a medical review or a nurse review of the medical records, often the claims specialist will just copy and paste the vast majority of the denial letter. That is not a reasoned and principled decision making process.
How long should your long-term disability appeal be?
We’ve seen many appeal letters. And we’ve drafted and filed many appeal letters. The common theme that I see regarding the length of the appeal is that short 1-2 page appeal letters are never sufficient to change the insurance company’s mind. Often, our appeal letters are 20-60 pages long, single-spaced. In order to cover the material and prove that you are disabled, you have to cover all of the issues.
How many long-term disability appeals to I have?
ERISA disability policies dictate an administrative review process that includes an internal appeal. Most long-term disability insurance policies allow for one and only one appeal. However, some insurance policies will allow a second appeal.
What is the first thing to do after being denied benefits?
What is the first thing you should do when you are denied long-term disability benefits? Request the entire claim file. The insurance company is required to give you everything they considered in making a decision in your case. You get to review every piece of paper. Request the claim file and you can see how the insurance company wrongfully denied you.
Can I settle my ERISA Disability Claim?
Can you settle your ERISa long-term disability claim? Yes, you can. However, most of the time, the insurance company will not make you an offer to settle until after your claim is denied, your appeal is denied, and you are litigating that denial in federal court. Once the insurance company becomes represented by an attorney, they will view the merits of the case and make a decision regarding settlement.
When do I file my long-term disability application?
Every policy is different and the first thing you should do is look at the policy to see what it says. However, in most cases, you have to file your claim and proof of your claim within 90 days after your elimination period ends. Your elimination period is usually 180 days from the date of your disability. So we are typically talking about 270 days, or 9 months from the date of your disability.
Don’t give up on your long-term disability appeal
You should never give up on your long-term disability claim because once your deadline passes, your ability to recover anything from that insurance policy is over. If you follow all of the deadlines for your appeal, even when it is hard, you may win and get exponentially more than you could get from social security disability.
Do I have to file social security disability after my claim?
Yes. Almost every insurance policy will require you to file for social security disability. Your LTD insurance company gets an offset for any other income you receive so they require you to apply because it means that they pay less. If you do not apply, or appeal if you’ve been denied, then the insurance company will estimate what you would get and deduct that from your monthly check.