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Winning Your ERISA Disability Appeal: 7 Strategies for Success

Feb 22, 2022 | Articles, Disability Law, ERISA, Long Term Disability

By Matthew DeGioia, Attorney

Over the years, I have seen ERISA Disability Insurance claimants inadvertently make costly mistakes when they are denied their Short-Term Disability and Long-Term Disability benefits.

Here are seven strategies for you to consider if a disability insurance company denies your claim for ERISA Disability Insurance benefits.

1. Do Not Appeal Your Decision Immediately

The most common mistake that I see in ERISA Disability Insurance cases is when a claimant files their appeal too soon. Generally, claimants are given 180 days to file an administrative appeal with their disability insurance company. Unless your appeal deadline is imminent, it is generally best to wait to file the appeal until you have new and material evidence that is sufficient to overturn the denial decision. At the moment you file your administrative appeal, the insurance carrier will review your claim based on the evidence in the record and any evidence that you submit with your appeal. Unless you have permission from the insurance carrier to supplement your appeal with additional medical documentation later on, the carrier will only consider all evidence submitted up until the day that you submit your appeal.

Notably, appealing a denial decision too soon can have significant consequences for your claim if you need to file a federal court complaint. When an ERISA disability claim is reviewed in federal court, the judge will only consider all of the evidence in the administrative record when making a decision. Generally, claimants do not have a right to submit new and material evidence when a case is undergoing judicial review. Filing an administrative appeal too soon can have serious ramifications down the road if you are denied by an insurance carrier a second time.

2. Identify the Reasons for Why Your Carrier Denied Your Claim

Many people think that simply submitting an updated clinical note or medical report is sufficient to overturn a denial of benefits. Whether that strategy is successful or not will depend on the basis of the disability insurance company’s denial of your claim. For example, if your Long-Term Disability benefits are terminated after 24 months due to a mental illness limitation in your policy, submitting additional medical evidence documenting your limitations caused by bipolar disorder or depression will not overturn the insurance carrier’s decision. It is essential to know why the disability insurance company denied your claim for benefits and specifically address those issues when submitting your appeal.

3. Request a Copy of Your Disability Claim File and ERISA Disability Insurance Policies

Not only should you know the reasons why the insurance carrier denied your disability claim, but you should also know what evidence they relied on to make their decision on your claim. The Department of Labor affords ERISA disability insurance claimants the right to review their disability claim file if they receive an adverse benefit decision on their claim. The claim file should contain copies of your ERISA disability insurance policies, all of the evidence that the insurance carrier received and considered, as well as all of the medical and vocational opinions that they relied on to make their decision. In most instances, insurance carriers will depend on the opinions of third-party medical reviewers to determine whether you meet the definition of disability in your ERISA disability insurance policy. Having the opportunity to review these opinions will help you know what you have to refute in your appeal.

4. Read Your Disability Insurance Policy

Every disability insurance claimant needs to be familiar with the key provisions of their Short-Term and Long-Term Disability insurance policies. Concerning an appeal, you should know the Definition of Disability that you will need to meet to overturn the carrier’s denial decision (i.e., whether you cannot perform the material duties of your Regular Occupation or Any Occupation). You should also be aware of any Exclusions that may preclude you from qualifying for benefits, including Preexisting Condition Exclusions mentioned in the policy. Further, you should be mindful of any Limitations Clauses that limit payment of benefits to a certain period (e.g., 24 months) for a disability caused or contributed by mental disorders, substance abuse, or subjective symptoms such as chronic fatigue or chronic pain. Other parts of your policy that may be helpful for you to be aware of include:

  • Minimum Hourly Requirement and Class of Employees Covered
  • Maximum and Minimum Monthly Benefits Payable
  • Maximum Benefit Period
  • Other Income Earnings (vital if you are receiving public benefits or income from any other source)

5. Continue Treating with Your Doctors

To have a successful appeal, you need supporting evidence. That evidence is generated every time you see your treating medical providers and accurately report your symptoms and limitations. The more regularly you treat with your medical providers, the more persuasive their medical opinion of your disability will be before a decision-maker. While an insurance carrier is not required to accord special weight to the opinion of your treating medical providers, an insurance carrier cannot arbitrarily ignore evidence that they submit. If the insurance company rejects the opinion of your treating physician, it must give reasons for adopting an alternative opinion. The insurance company also legally cannot ignore evidence supporting disability from your treating medical providers by failing to make a reasonable effort to speak with them. A treating doctor’s opinion holds more sway if you have a lengthy and consistent treatment history with them. Continue treating with your doctors.

6. Consider Undergoing an Independent Examination

Often what is needed to refute the findings of a third-party medical reviewer hired by an insurance company to review your disability insurance claim is an independent examination. In disability insurance claims, a Functional Capacity Evaluation (FCE) is generally a reliable and objective method of gauging the extent one can complete work-related tasks, especially when a claimant complains of pain or other subjective symptoms. Similarly, a Vocational Evaluation (VE) may be helpful to determine whether there are any jobs in the national economy that the claimant can perform given their symptoms and limitations, especially if the claimant is required to prove that they are unable to perform the material duties of any occupation for which they may reasonably become qualified based on education, training or experience. After undergoing both of these evaluations, it is typically best practice to have a treating physician corroborate the findings of these evaluations in a follow-up report.

7. Hire a Disability Benefits Lawyer

As you can see, navigating the appeals process can be a minefield. The way disability insurance companies process ERISA claims is far from intuitive. More often than not, prevailing on a claim requires more than simply submitting an updated doctor’s note or medical report. I highly recommend contacting an experienced ERISA disability insurance lawyer to assist you with deciphering your disability policy, informing you of your rights and responsibilities on appeal, and helping you put together the best argument you can make to overturn an insurance company’s denial of your claim. Contact me today for a free consultation at 301-563-6685.


About Andalman & Flynn, P.C.: Founded in 1998 in downtown Silver Spring, Maryland, Andalman & Flynn has forged a distinguished reputation for legal excellence. The firm represents individuals seeking disability benefits throughout the country and practices family law throughout Maryland and the District of Columbia. The firm focuses on cases that impact the rights of everyone, and are there for clients when responsive legal help is most critical. The firm has provided legal analysis on national and local television and radio, and their attorneys often testify before legislative bodies and are routinely invited to contribute to prominent legal publications. For more information about Andalman & Flynn, please visit the website at andalmanflynn.com or call 301.563.6685


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