Is a Disability Lawsuit Harder To Win Than an Appeal?
My name is Brandon Osterbind and I’m an injury and disability attorney here in Central Virginia. I help people whose long-term disability claims have been denied. Today, I’d like to answer the question, “Is it harder to win a disability lawsuit than an appeal?”
What to do when your benefits have been denied
First, let’s define what we’re talking about. An insurance disability appeal comes after the insurance company has denied your claim for long-term disability benefits. As a result, you are appealing the insurance company’s decision within the insurance company.
If the insurance company denies your claim for long-term disability benefits again, and there is no secondary appeal process in your policy, then your only recourse is to file a federal lawsuit in the federal district court in the jurisdiction where your employer or you live. So you file that claim in federal court.
What happens in federal court
And what happens there? Your claim is reviewed for an abuse of discretion. You will not have an opportunity to testify. You cannot tell the judge or a jury what happened to you and how it affects your life. Everything that the judge reviews in deciding your case is decided based on information that you have already provided to the insurance company in the appeal.
Abuse of discretion
The appeal review standard is called an abuse of discretion. Almost always, the policy gives the insurance company the discretion to grant or deny your benefits. And if the question is discretionary, then the review is for an abuse of discretion, which is a very high standard for you and a very low standard for the insurance company.
Here’s what we often see. You, as the claimant, have your doctors, who say that you’re unable to work. And the insurance company will have their doctors that say that you are able to work and that your medical condition is not so serious that you shouldn’t be on the job. So you’ll have this battle of the experts.
Battle of the experts
The court will look at it and say, “Well, was it unreasonable for the insurance company to rely on this particular doctor’s opinion?” And if the answer is no, like it so often is, then the court will dismiss your claim.
Then again, the answer may be yes, because that doctor only reviewed the records and didn’t even review all of the records. And he or she had an opportunity to perform an in-person medical examination but didn’t do that. These are some of the considerations that the court may consider.
But the court could also look at the case and say, “It was 100% unreasonable for the insurance company to rely on this particular doctor’s opinion when five of the claimant’s doctors have already said that he’s disabled.”
If all the claimant’s doctors are agreeing that you’re disabled, then why would the opinion of this one “expert,” who only reviewed the medical records, trump all of these other four or five doctors? It shouldn’t. Therefore, the insurance company abused its discretion in denying the claim.
What may happen next
In the end, the court will remand the case back to the insurance company for further consideration based on what the court said. Then the insurance company will typically put you back on claim at that point or award your benefits in the first instance. And you may get a large lump sum of money based on the past due benefits.
The long and short of it is, yes, it is harder to win a disability lawsuit than it is to win an appeal because the standard is stacked against you. It’s a high burden for you and it’s a really low burden for the insurance company. I hope this post has been helpful and I hope that you learned something from it.
What you should do
If you have been denied long-term disability benefits, let us or another attorney help you at the appeal stage. You have to make sure that you equip the insurance company and ultimately the federal district court judge with enough information to say that the insurance company abused its discretion when it denied your long-term disability benefits in the first place.
If you can stack the insurance company’s file with information that would make it look unreasonable for disagreeing with your doctors, then you have a better chance of winning your case in court. If you have any questions, give us a call or send us an email. Let us know how we can help you either get your benefits awarded or stay on a claim.