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Claim Denied By Aetna? Tips To Help Strengthen Your Appeal

Aetna is one of the largest and best-known disability insurance providers in the United States. The company has been known to collect tens of billions of dollars in revenues from premiums alone. As you can guess, Aetna is not always so quick to pay valid long-term disability (LTD) claims to policyholders and will do what it takes to retain every cent of their annual earnings.

Millions of American workers have LTD coverage with Aetna. If you suffer a disabling sickness or injury that prevents you from working for an extended period, you may have the right to receive monthly LTD insurance benefits. These monthly disability insurance benefits will provide supplemental income to help cover your needs and expenses while you are not receiving a paycheck. A basic understanding of the claims and appeals process will help before beginning any lawsuit against a well-funded organization like Aetna.

The Basics

When an injury or illness limits or prevents you from working, you will want to file for LTD benefits. The insurance provider is supposed to, in a timely manner, pay you benefits if you suffer from a covered sickness or accidental disability, but there are limitations you should know.

For example:

  • You need to miss a certain number of workdays before your disability benefit satisfies the elimination period. This timeframe is called the waiting period and typically runs for 30, 60, 90, 180 or 365 days.
  • Disability insurance benefits last for a specific period of time. Your age at the time you become disabled and your contract terms will determine how long monthly benefits last.
  • The amount of disability insurance benefits you receive is usually based on your hourly wage, salary, commissions, and other forms of income or bonuses from your employer, or your self-employment income depending on your disability plan.
  • Other incomeyou receive or are eligible to receive during your disability may affect the amount of disability benefits you are paid. Check your policy offset section to see if your policy offsets for other income you are eligible to receive, or that you have received.
  • Aetna may also try to require you to undergo rehabilitation services to help you return to work, so check your policy carefully.

Prepare For Denials

LTD claim denials are unfortunately par for the course when it comes to filing long-term disability insurance claims. If you have been denied, do not be deterred. Follow these three critical steps to properly address the denial by Aetna:

  1. File an appeal if you must, to get a second independent look at your claim. You can submit your request in writing, but don’t do so without first reviewing your strategy with a seasoned long-term disability lawyer.
  2. Lawyer up. It is a very good idea to schedule a free consultation with a nationally recognized long-term disability attorney as well because Aetna has a packed legal department that will vigorously protect the company’s interests. You need a disability practitioner whose main focus is disability insurance law. This lawyer will have insight into the claims and appeal process and work for you with the goal of getting your denial overturned.
  3. Be sure to keep detailed records of all correspondence, care, and treatment. This will better position you and your lawyer if a dispute arises about what information was submitted. Furthermore, the lawyer will review your documents and possibly identify patterns of tactics used by the insurance company to delay or deny your claim.

When any insurance company uses tactics to delay and deny coverage and avoid paying legitimate claims, they may be acting in bad faith or arbitrarily. This is unlawful and could result in a civil or ERISA lawsuit.

Aetna has been to court for bad faith individual disability claims and has lost notable cases and had to pay their disabled insureds. For example: in Sherrie Ace v. Aetna Life Insurance Company (1998), they ultimately had to pay a combined $127,000 for wrongful denial and emotional distress damages. Convincing a jury regarding bad faith is challenging, and a seasoned bad faith disability lawyer is best suited to handle these individual disability matters.

What To Expect After An Appeal

If you need to exhaust the appeals that your plan or policy requires, you may file your individual complaint or group ERISA complaint for disability benefits.

The Employee Retirement Income Security Act of 1974 (ERISA) is a wide-ranging federal statute that applies to U.S. employee group disability insurance benefit plans, when those plans are provided by private employers or labor unions. Like other parts of some employee benefit packages, disability insurance plans are subject to ERISA. Pertinent parts of ERISA include reporting and disclosure rules along with certain prohibited transactions.

Aetna can face liability, under ERISA provisions, for not telling you enough about your disability plan. Aetna also has a duty to make you aware of your policy provisions in ways that the Federal courts deem adequate.

Contact a Disability Claims and ERISA Lawyer

If Aetna has failed to meet its obligations by delaying, denying, devaluing or terminating your claim, our top-rated disability insurance bad faith and ERISA lawyers offer free consultations to discuss your situation.

Understand your policy and your consumer rights before filing your valid claim for individual or group long-term disability benefits. Our experienced ERISA lawyers and award-winning individual disability attorneys at DarrasLaw can review the terms of your disability insurance policy, help you understand your rights, and recommend claim form or treatment suggestions. Contact us today (866) 276-3054.

 

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