By Peter Casciano, Esq., 301.563.6685
There is no one way to prevail on an administrative appeal of a Long Term Disability (LTD) claim denial. In some cases, a more thorough explanation in support of the claim from a treating physician can do the trick. In some cases, it’s imperative that you squarely rebut the reports generated by the doctors hired by the insurance company (typically referred to as File Reviews or Independent Medical Examinations). Other times, we need to hire our own independent experts for their opinions. In some instances, we need to carefully parse the terms of the policy to make sure the insurance company has followed them correctly. In almost every case, some combination of the above is necessary.
My advice across the board is that it is never a good idea for claimants to file their own admin appeals after being denied. First, even the most medically literate claimants don’t have the requisite perspective to assess the strengths and weaknesses of their claim. Also, the claimants are sick or injured. Dealing with the claim is often too much to handle, even with help from loved ones. I routinely hear from claimants how relieved they are to turn the case over to me and concentrate on their health. Lastly, a proper admin appeal takes hours of time, connections with experts, years of experience reviewing claim files and a deep knowledge base of all the federal cases analyzing LTD approvals and denials.
Assuming you are dealing with a claim covered by the federal law ERISA, you will have 180 days from the date of the denial to file your administrative appeal. Many folks I have spoken with are so angry when they receive the denial letter that all they can think about is suing the insurance company. Frankly, I don’t blame them. However, ERISA specifically bars claimants from running to court after receiving the denial letter. ERISA mandates that claimants first file one administrative appeal of the denial with the insurance company.
There are two key takeaways to mention at this point: first, don’t miss the deadline. Missing the 180-day deadline makes the difficult task of winning the administrative appeal even harder.
Second, it is possible to win administrative appeals. I’ve come across a lot of misinformation stating it is fruitless to try to win administrative appeals. I disagree. While I cannot guarantee a win, I can say that I win many LTD admin appeals. Filing a well-reasoned appeal, with strong, objective evidence, is always the best practice. Filing a strong appeal is always a good idea. Aside from trying to win the administrative appeal outright, it improves the underlying record that will be at issue in the final court case. The right attorney will know how to cover both bases so that if you lose your admin appeal, you still find yourself in a strong position. It’s a good idea to make sure the attorney you choose has experience litigating LTD cases in court.
Some kinds of evidence that help on admin appeals are not always obvious. We have filed journals kept by our clients detailing their symptom flares and how they dealt with them. Sworn statements from loved ones who witness the day to day aspects of claimants’ lives can be helpful. We have even submitted clients’ “day in the life” videos documenting what it’s like to live with their injury or illness.
There are sometimes other disability cases proceeding on a parallel track to the LTD case. The most common kind is the social security disability case. A common mistake is to assume that you know what evidence is in the SSDI claim file. It is always a good idea to obtain the SSDI claim file and mine it for evidence that may support your LTD admin appeal.
A proper LTD admin appeal will always engage the evidence located in the insurance company’s claim file, which can be overwhelming. The right attorney knows how to review the insurance company claim file. The right attorney knows the format these claim files usually follow, and what information to look for when reviewing the hundreds if not thousands of pages they contain.
The right attorney will also be familiar with your specific injury or illness. Certain types of objective tests usually fit well with certain kinds of illnesses or injuries. That kind of real-world experience puts the veteran attorney in a strong position to support your admin appeal with the right expert evidence. Many claimants make the error of assuming that their treating physicians will refer to them to the correct expert for testing. This is wrong not because their treating physicians are unqualified or unhelpful, but because the kind of testing we obtain is not always done with treatment in mind. The exams we routinely use incorporate an opinion regarding the claimant’s ability to work or functionality. I cannot stress how important objective testing can be in the world of disability benefits. It is true that many policies do not require that the claimant provide objective testing. However, providing objective evidence, if possible, is always a good idea, even if not expressly required in the policy.
Please think these issues through when appealing your claim and make sure that the attorney you choose is doing the same. For folks with any questions regarding LTD admin appeals, I offer free consultations. We can strategize the claim, its strengths and weaknesses, how I would approach it, and what the likely expenses will be. ERISA provides claimants with 180 days to file the admin appeal for a reason. Convincing the billion-dollar insurance company that its first decision was wrong takes time, planning and experience. Please make sure that you have an attorney on your side who knows how to maximize your chances of winning.
About Andalman & Flynn, P.C.: Andalman & Flynn, P.C. serves clients throughout Maryland and the District of Columbia, offering compassionate, quality service and results-driven representation across a broad range of legal areas. With a concentration on disability benefits law and family law, the firm focuses on cases that impact the rights of everyone, and they are there for clients when responsive legal help is most critical. For more information about Andalman & Flynn, please visit our website or call 301.563.6685.