A claim denial doesn’t have to be final. Here’s how to write an appeal letter to get your benefits covered.
An injury you suffered at work is usually covered under your employer’s workers’ compensation insurance. Employers also provide long-term disability (LTD) policies, which are part of the Employee Retirement Income Security Act (ERISA). ERISA is a federal law that protects employees and their beneficiaries who are entitled to receive benefits from retirement and welfare plans.
Even though an LTD policy is intended to protect you, sometimes the claims process is difficult to navigate and claims can be denied for several reasons. If you’ve filed a LTD claim and are denied, there are 2 levels of appeal so you can get the benefits you need and deserve.
Ask your employer or former employer for a copy. If you purchased the policy yourself (not through an employer), contact the agent who sold you the policy or the insurance company in order to obtain a copy.
Common reasons for denials of long-term disability claims
It’s important to understand why a claims administrator might deny your claim because that information could help your argument if you end up filing a lawsuit.
These are 4 common reasons why claims are denied:
1. Insufficient medical evidence
In order to show that your disability is ongoing and debilitating enough for you to continue to receive benefits, you must be under the regular care and treatment of a physician.
If your injury is physical, your doctor should be giving you periodic objective diagnostic testing like x-rays or MRIs in order to see if your condition has improved, worsened, or remained the same.
If your injury is emotional or psychiatric, you should be having regular and ongoing visits with a mental health provider.
If you’re doing all of these things, it’s also crucial that the documentation is provided to your insurance company in a timely way. Your medical providers need to be routinely sending reports to the insurance company so its records are updated and accurate. You should also ask your doctor to write a letter that details their findings after each visit (or at certain intervals) and send it to the insurance company.
Sometimes, the insurance company’s forms are designed to ask questions that would be more likely to be answered in a way that supports a denial. But if your doctor believes that you’re disabled and provides their opinion in their own words based on their observations, the insurance company must honor that.
A denial based on insufficient medical evidence could also be nothing more than a clerical mistake. We’ve all been in situations where a payment was lost, a computer glitch changed numbers, or some other technical fail created problems. If you receive a denial based on insufficient medical evidence, ask the insurance company what documents it has. If it doesn’t have enough documented evidence from your medical providers, it’s possible that the information was lost in transition from the doctor’s office to the insurance company, misfiled, or otherwise misplaced.
These things happen. Check the insurance records to find out whether the company actually has everything it should.
2. Claim doesn’t meet the definition of disability under your policy
There are 2 types of disability policies.
- Own occupation: In this kind of long-term disability policy, you’re considered disabled if you’re unable to perform the tasks associated with your specific occupation.
- Any occupation: This type of policy defines a person with a disability as someone who’s unable to perform the duties for any job.
Many policies will automatically transition from an “own occupation” plan to an “any occupation” plan after a person has been disabled for 24 months.
Some LTD policies have exclusions, like pre-existing medical conditions or impairments related to substance abuse. There are also conditions that can’t be diagnosed through objective methods (like blood tests or MRIs, for example), but for which the diagnosis relies on the patient’s own description of symptoms (like chronic fatigue syndrome). Those policies are often limited to 24 months of benefits.
3. Your condition doesn’t match the insurance company’s surveillance reports
Yes, this is real. It’s not just on TV that an insurance company will send an investigator to “catch” a claimant doing something they said they couldn’t.
Some conditions, like fibromyalgia, can be debilitating one day and “fine” the next. Being on and off like that isn’t conducive to holding down a job, but it means there might be some tasks you can do on your good days.
But be wary.
Some benefits providers have investigators who will take surveillance photos or videos if you do something the insurance company doesn’t think a person with your condition would do. If you’re receiving LTD benefits for fibromyalgia, for example, but an investigator records you riding a bicycle, it would seem to the insurance company that your disability isn’t as bad as you’ve reported.
You don’t have to hide your every move, but act in accordance with your doctor’s recommendations. If the doctor has recommended that you use a cane, use it. If you’re not supposed to carry a load more than 25 pounds, don’t.
4. You concealed a material fact on your application
If the benefits application for long-term disability asks for the name of every doctor you’ve seen in the past 10 years, provide that information.
There could be a doctor who you only saw once because you didn’t like their bedside manner, or maybe because they didn’t assess your condition in a way you thought was accurate. Regardless of the reason, your medical history is a material fact and it all needs to be included.
Failure to disclose any material fact on your application could give the benefits provider the right to void your policy.
How to appeal a long-term disability denial
Your claim was denied. Now what?
You can begin by writing an appeal letter to the insurance company.
Is there a deadline to submit my appeal?
Yes. ERISA sets forth a 180-day deadline to file your appeal. If you miss the deadline, you no longer have a right to appeal your case for long-term disability benefits.
Here are 3 tips for what to include in your appeal and how to proceed.
1. Make sure you understand why your claim was denied.
You should have received a letter from the insurance company that explains why you were denied. Read that letter carefully. It will tell you:
- Why your claim was denied
- Your appeal deadline
- What additional documents you need to file an appeal
If there are portions of the letter that you don’t understand, seek help. A disability insurance lawyer can work with you to interpret the letter correctly.
2. Request a copy of your claim file.
Your claim file contains every piece of information the insurance company used to evaluate your claim.
Here’s how to make a request for your claim file:
- Send a request directly to your claim administrator.
- Provide any claim numbers you have in your documents, and copy your request to any claims examiners included in your denial letter.
- Send your request by certified mail with return receipt or by fax with a confirmation so that you can prove that the insurance company received it.
- Keep a record of when you made the request, proof of receipt, and any follow-up requests.
- If you receive your claim file and believe there are documents missing, you can follow up with a specific request for that information.
3. Gather your supporting documents.
You want to present as much information to the insurance company as possible for your appeal. If your policy is governed by ERISA, you will not be able to add to your claim file after this point. If you end up going to court, the judge will only review the material in your file at the time of the appeal.
Here are some of the documents you should have in your file:
- Employment records showing how your condition affects your work.
- Written opinions from doctors, therapists, or other medical providers.
- Statements from family or friends declaring facts about your condition and how it affects your life.
- Any medical records that are missing from your original claim.
- Any medical records that are more recent than when your original claim was decided.
- A schedule of future appointments, tests, and expected expenses related to your claim.
There might be other documents, too, that are specific to your claim.
If you’ve been approved for Social Security Disability or VA compensation, or are receiving benefits from any other agency, that’s important because it shows that other entities have determined you’re unable to work. Be sure to include approval letters, benefit statements, or any other documents you have from other agencies with respect to your disability.
How to write your disability appeal letter
Format the letter as you would any business correspondence. The person reading your appeal letter likely has a stack of dozens — perhaps hundreds — of letters on their desk, and you want to make the process as easy and quick as possible for them. If they have to wade through irrelevant information, search for the important parts, and figure out what you’re trying to say, it might delay the process.
At the top of your letter, include the following information:
Claim number: [claim number or social security number]
If your letter is more than one page, include this information on the top of each page in case anything gets separated. You should also put this information on each document you submit.
You might want to type your name and claim number on adhesive labels and affix one to the top or bottom of each page of information. That way, if your records become separated from your letter, it makes it easier for the insurance company to piece your file back together.
The labels should be on the front of each document (but not covering any information) in case the insurance company scans pages for digital recordkeeping. If the document is 2-sided, place a label on each side that has relevant information.
The body of your letter should explain why you’re filing an appeal.
- Submit missing information. If there was missing medical information, note specifically what it is. Let the examiner know that you’ve included documents to fill in the gaps from your previous submission.
- Correct any mistakes. If your denial was based on incorrect diagnoses, mistakes about your work history, or for some other reason, set the record straight (and include the necessary documents to prove it).
- Update your condition. Perhaps your condition has worsened since you filed the initial claim. If there are new test results, a more detailed (or different) diagnosis, or additional medical information that wasn’t available for the initial claim, let the examiner know why the situation is different now.
If there’s more than one reason why your claim was denied, or why you believe the denial was incorrect, set forth each argument clearly and separately. Use bullets, make a numbered list, separate paragraphs — whatever feels right to make a clear and readable list that makes sense.
Be sure that if you’re providing new information, you include contact information for yourself, and any medical providers or other people included in the documents.
When to hire a disability lawyer
Since the deadline for filing an appeal is non-negotiable, it’s best to act quickly.
Hiring a lawyer to review your appeal letter before you submit it to the insurance company is a smart move.
Keep a couple things in mind when deciding when to hire a disability lawyer:
- You only have one appeal. If it’s denied, the next step is filing a lawsuit. That becomes a lengthy process, costs money, and still doesn’t guarantee your benefits.
- You can’t submit new information in court. The judge will only review the information submitted in your initial claim or appeal.
A lawyer might be able to spot other kinds of documents that you might not think of to support your appeal. Because of their experience handling years’ worth of long-term disability denials, an experienced lawyer can craft arguments in a way that are more compelling to the insurance company.
Unlike a personal injury claim, this isn’t a negotiation process with a back-and-forth between you and the insurance company. It’s a one-shot appeal, and then you have no choice but to go to court if you don’t get the satisfaction you need.
That’s why calling a disability lawyer as soon as you receive a denial of your claim can be a huge help. They will know what to do and how to do it so you don’t miss your chance to have your claim covered, and hopefully avoid going to court.
Start your search with the Enjuris Personal Injury Law Firm Directory to find a lawyer in your state who handles insurance, workers’ compensation, and disability claims.