How to Write An Effective Long Term Disability Appeal Letter
If your disability insurance claim was wrongfully denied, you are likely wondering what options you have to secure a different outcome.
Of course, lawsuits are possibilities, but sometimes, you can’t sue immediately. With employer-sponsored disability insurance, companies require that you exhaust their administrative appeals before filing your federal ERISA case.
Disability insurance companies usually have their own internal protocols for reviewing disability claims that they’ve denied. This allows these companies to ensure that they have not overlooked pertinent documentation, misjudged treating doctors’ statements, failed to investigate disability claims in good faith, etc. Sometimes, this first appeal leads to an individual insurer’s decision to change its initial denial—but not often.
In other cases, the insurance company still chooses to uphold its original denial of your disability claim. Some insurance companies have a second-level internal appeal for group disability policies, where you must timely appeal again through the insurer.
During this second appeal, the group disability insurer may request new items from you, such as more information from your doctor, or judgments from its own hired doctor (some of whom lack the proper credentials to accurately evaluate your disability) at its expense—such as independent medical examinations and functional capacity evaluations.
If your group disability insurer upholds your original denial a second time, you generally have the right to sue under ERISA in federal court.
If your group employer-sponsored disability claim is denied on the first and second appeals, your insurer must tell you why each time. It should cite legitimate reasons and evidence that support its decision. Whatever reason your insurance company gives you, it will provide experienced disability insurance lawyers, such as those at DarrasLaw, a basis on which to independently evaluate inaccuracies.
How To Decide Whether To Pursue An Appeal
If you have been denied a long-term disability claim through your insurance company, you have the right to appeal the decision. It is in your best interest to hire a long-term disability lawyer to guide you through the process, but it’s also helpful to do some research on your own. The appeal process is tricky and involved.
Here’s what you can do to get started:
You need to ask yourself two questions before sitting down to write your appeal letter.
- Is there any compelling new evidence that would make your claim better now than it was when you originally submitted it?
- Is there a typo or some detail that needs correction to get your claim filed successfully?
If the answer to these questions is “no,” that doesn’t mean you should give up on the appeals process. It simply means there’s more planning and research ahead. Of course, an experienced lawyer can drastically lighten your load and provide the guidance you need.
What To Research Before Pursuing Your Appeal
First, you will need to obtain a copy of your complete long-term disability file. Trying to appeal a denial is almost impossible without a copy of the file itself. Without it, you will not have enough information, which will put you at a serious disadvantage. You’ll need more than just the short description in your denial letter, so you’ll need to contact the insurance adjuster who denied you in the first place and tell them that you wish to appeal the decision, and you will need a complete copy of your file.
Now that you have your file in hand, it’s time to dig in. The goal is to understand why the claim was denied in the first place. Take notes. After reviewing the available information, you may find that the denial was based on lack of documentation, surveillance showed that you were not disabled in their view, or it could be something such as legal errors.
You should also obtain all documents from your medical providers, including reports from your primary care physician, psychologist, and any specialists that have been instrumental in your treatment process. Medical documentation can provide you with essential information that will support your claim and directly contradict denial reasons.
Make sure that you clarify anything that may have been overlooked or possibly misinterpreted in the denial and gather the supporting documentation that clarifies any misunderstandings.
Once you’ve done your due diligence to understand the denial and gathered and reviewed the documents that can make a difference, your next best step is to contact an experienced long-term disability lawyer to help draft your appeal letter.
Writing Your Appeal Letter
As you have likely realized, filing a timely administrative appeal is extremely important. It involves writing a formal appeal letter and attaching all your supporting documentation.
Your letter should be drafted in a persuasive and well-written manner with proper formatting. It should be non-argumentative and contain clear language. Make it personal to your situation, detailed, and honest. Insurance companies are suspicious of everyone who files a claim. They are paid to find exaggerations, inconsistencies, and false information. Do not try to mislead the insurers. Stick to the objective research and facts you have at hand.
Though insurers and their requirements vary, letters should typically include:
- The reasons the insurance company cited for your wrongful denial. Now is not the time to be vague in your details. Many denials are based on the insurance adjuster’s perception of your injury. It is your job to present all of the evidence so that it cannot be misunderstood.
- Your specific coverage or policy’s language that supports your disability claim, including all medical, financial, vocational, and legal case law that supports your position.
When writing your appeal letter, or even when simply documenting an appeal, consider attaching the following, even if it is not requested:
- Your medical condition. Thoroughly explain the objective and subjective testing you’ve undergone and how your limitations prevent you from working.
- Specific reasons, with references to your policy where possible, why you believe your disability claim is covered and, therefore, your denial is wrongful.
- Contact information for you, your treating doctor, and anyone who can validate your symptoms, limitations, and disability.
If you include only the information you included in your original disability claim, you will get the same bad result. Consider consulting one of the seasoned, top-rated disability insurance appeal lawyers at DarrasLaw to discuss the types of additional documents you may choose to add to your appeal.
These may include:
- Any documents providing additional information that your insurance company has questioned in your denial letter
- Notes and dates from as many phone and email conversations as you had with relevant professionals that support your disability claim.
- New or updated medical reports, including your treating doctor’s line-by-line refutation of the insurance company doctor’s reports.
Your Step By Step Checklist
- Note the strict timeframes. The denial letter will outline the strict and unforgiving deadlines and specific requirements for filing your administrative appeal. Missing the appeal deadline is fatal—it will make reversing your wrongful denial nearly impossible. A seasoned ERISA disability insurance attorney at DarrasLaw can make sure you meet every deadline and successfully eliminate any “proof of loss” denials.
- Don’t ignore details in the denial letter. The broad strokes are important, but pay very close attention to the details of your denial letter. Take your time and hire appeal counsel experienced in federal ERISA law. Hire an experienced, top-rated disability insurance lawyer at DarrasLaw to assist you in preparing and submitting your appeal.
- Don’t panic. No one knows the details of your situation better than you. Adhere to deadlines, reach out to experienced ERISA appeal counsel if you have unanswered questions, but don’t panic. Get help!
- Gather information. Request copies of your insurance policy or certificate and your administrative record from your insurance carrier ASAP. Examine the denial documents for any incorrect and incomplete information. Check the reasons they have given you for why your disability claim was denied. Your insurer will likely have pointed to specific policy provisions and limitations that it feels support the denial. Check your policy. See whether your policy matches the language, provisions, and limitations the insurer has used to deny.
- Carefully compose your administrative appeal letter. Consider creating a cursory list of the issues that your insurer cites and with which you disagree. This can function as a sort of outline for your appeal. Next, try to find evidence or documentation to support each of your positions—the more, the better. This will help you remain organized and well-reasoned, while also easing any frenzy you may feel due to the nature of this process.
- Ask for help. Doctors and vocational experts are often happy to write letters in support of an appeal, but you have to ask, and you can’t win without their written support. Your treating doctor or vocational expert needs to provide comprehensive information to better document your disability claim—new chart notes, new tests, etc.
- Provide proof of disability. Often, one insurer denies a person while the Social Security Administration approves the same person’s separate disability claim. If you’ve received Social Security Disability Insurance (SSDI), include these documents in your administrative appeal.
- Include your friends and family’s declarations and statements. Often, insurance companies hire private investigators to monitor your daily activities to disprove your disability. You may counter this with written accounts from family and friends detailing your disability, treatments, and side effects over a much longer period than those close to you.
- Meet all deadlines. As mentioned, appeal deadlines are set in stone, and few exceptions are granted. Missing a deadline could mean going without the benefits you need.
You Don’t Have To Do This Alone. Contact DarrasLaw
We have provided some important tips for writing your administrative appeal letter. That doesn’t mean you have to go through the process alone, and you shouldn’t.
If your insurer lets you down, we are here to assist and fight for the benefits you deserve. We can offer immediate help through our free claim consultations and policy analysis. Reach out to us, and let’s discuss your options. Call DarrasLaw today at (800) 458-4577 or contact us online.