Many advocates that help people who have been denied benefits from disability insurance companies like Unum note that in a large number of cases, the firm will issue a denial simply as a matter of course. However, there are several things a person can do to appeal the denial and get the benefits they deserve.

Why Do Long Term Disability Claims Get Denied?

There are many possible reasons as to why a long term disability claim may have been denied. In some cases, claimants may not actually be eligible for the benefits they are trying to claim under the terms of their policy. In other cases, however, the insurance company may simply require more information in order to grant benefits. In your denial letter, your insurer should cite the specific reasons why it has denied your claim.

Common reasons why a long term disability claim gets denied include, but are not limited to, the following:

• Not meeting the definition of “disabled” under the terms of the policy
• Having an excluded or pre-existing condition
• Missing medical records
• Insufficient evidence of the disability
• Self-reported symptoms (rather than hard records)
• The insurance company’s doctors disagree with the claimant’s physician
• The claimant being caught doing things their disability would prevent them from doing

Disability claims get denied for valid reasons every day, but so too are valid claims denied. Receiving a claim denial is not the end of the road, but instead the beginning of a process that may yet result in you receiving the benefits you’re owed—often without pursuing litigation at all!

What Is the Disability Appeal Process?

If your disability claim was denied, don’t worry! This just means it’s time to start the disability appeal process. The first and most important step is to thoroughly read and review your denial letter.

First, you should get a copy of your long-term disability policy. These documents will include a summary plan description and detailed information about your policy’s terms. Although this information may be hard to get, you are owed a copy of your long-term disability policy for free under federal law.

Next, you should take a close look at your denial letter. The letter should provide a detailed reason for your denial and an explanation of the disability appeal process. Together, your policy terms and denial letter can provide important information that can help guide your appeals process.

It may be helpful to work with an advocate or disability insurance attorney to obtain doctors’ records and, in some cases, the opinion of an outside medical expert. If a long term disability claim is denied a second time, the plaintiff can take the company to court for an administrative hearing. Unlike in most civil claims, these are not heard before a jury, which is why legal expertise can be beneficial.

Even then, a disability insurance attorney has to take note of the judge who is hearing the case. Tactics may differ depending on who has drawn the case. However, regardless of the judge, the appeals process is governed by a number of rules. The critical one for people looking to get the disability insurance benefits they feel they deserve is the 60-day time limit to file an initial appeal.

If, even after filing a comprehensive appeal, your claim is still denied, you may want to speak to a qualified lawyer for disability appeal assistance. Once you exhaust all administrative appeals, you have legal standing to file a lawsuit against the insurance company. An experienced attorney can help you take this step and potentially recover benefits with interest, even after a denied disability appeal.

In fact, after the initial denial of disability insurance, beneficiaries should review the entire contract, and if necessary get one from their employer. The language within may govern how the process works, and in most cases includes wording which requires the administrative hearing. It can be a somewhat arcane process, but roughly two-thirds of all cases that are initially denied are eventually approved.

How Long Does a Disability Appeal Take?

Under federal law, all insurers must give people at least 60 days to file an appeal. However, many long term disability policies actually allow more time—check your specific policy to see exactly how much time you have and make sure you don’t miss any deadlines. However, while deadlines are extremely important, it is just as important to be thorough as it is to be on time.

Prudential Long-term Disability

According to the company’s website, Prudential long-term disability helps “protect your income” in the case of disability. Although short term disability provides income replacement for three to six months, Prudential touts its long-term disability as a solution for lost wages due to disability. Prudential offers a group protection plan that includes both short- and long-term insurance coverage, so that the long-term coverage can take over once the short-term insurance ends.

Reliance Standard Insurance

Reliance Standard’s website says that the company offers “employers—and their employees—a variety of options so they can get the coverage they need affordably.”

Reliance Standard’s group short-and long-term disability plan offers benefits up to 60 percent of salary.

Sedgwick Disability Claims

According to Sedgwick’s website, its insurance is meant to be “cost-effective, efficient and compliant.”

Sun Life Disability

According to Sun Life’s website, the insurance company offers “income protection and a path to wellness” through “income protection and the vocational and clinical support to move forward with their lives.  Sun Life offers a variety of long-term income replacement levels, from 40 percent to about 66 percent.

The Standard Long Term Disability

The Standard’s long-term disability insurance plans are meant for situations where a disability or illness prevents an employee from working for longer than 120 or 180 days. According to its website, this benefit replaces a certain portion (up to 60 percent) of your income, “helping you to meet your financial commitments in a time of need.”

Disability Appeal Letter Sample

In short, your appeal letter should be accompanied with any supporting documentation that you think would help with your claim. This can include the following:

• Medical records (physician notes, radiology reports, surgery reports, emergency room records, blood tests)
• A pain journal, if applicable (documenting your experiences and how your disability affects you daily)
• Written opinions from your doctor (including how your disability affects your mental and physical capacity for work)
• Letters from friends or family members detailing how your disability impacts your life
• Written opinion from a vocational expert
• Your personnel file from your work
• Statements about your work and your disability from your employer and coworkers

Under ERISA, you cannot add any more information to your file after you have finished with the administrative appeals process. This means that you should be sure everything you may need is accounted for.

If you aren’t sure what information you should include on your appeal letter, you can contact your claims agent. They will be able to tell you what information is required and what information may be helpful to you during the claim process. If your claims agent is unable or unwilling to do this, you can seek help from a qualified attorney.

It may be a good idea to consult sample appeal letters as you form your own appeal.

What to Do About a Denied Disability Appeal

Even after all levels of administrative appeal have been exhausted and your Sedgwick long term disability claim has still been denied, there is yet hope: you can turn to litigation.

One thing to note when filing a lawsuit over an insurance claim denial is that the judge can only consider evidence included in the original insurance claim and any administrative appeals that may have followed. At this point, you will not be allowed to submit any new evidence. This means that it is best to include as much relevant information as possible in your administrative appeals—not just to be thorough and have the best chance at having the denial reversed (though this is important too) but also so that, if you end up filing a lawsuit, you have all the evidence you need at your disposal.

A trained, experienced LTD lawyer can help in compiling your evidence and the fact that you have legal counsel on your side typically forces these companies to take your appeal more seriously. The primary reason is that such an attorney is well-versed in the federal regulations set out under the Employee Retirement Income Security Act of 1974 (ERISA), and use those rules to your benefit. This includes “stacking” the evidence with testimony from medical and vocational experts who are familiar with your disability issues and limitations.

Finding a Lawyer for a Disability Appeal

Obtaining experienced legal representation can be important when appealing a claim denial, especially given that the initial appeal can take more than a year. Unless plaintiffs can also take advantage of workers’ compensation benefits in the interim, money can be a real concern for them.

Appealing the denial of a long term disability claim can be complicated and even overwhelming, so Top Class Actions has laid the groundwork for you by connecting you with an experienced lawyer for disability appeal. You deserve to receive the full benefits you’re owed, and consulting an experienced attorney can help with that. If the administrative appeals process is exhausted, an attorney can then help you file a lawsuit against your insurance company.

Do YOU have a legal claim? Fill out the form on this page now for a free, immediate, and confidential case evaluation. The bad faith insurance attorneys who work with Top Class Actions will contact you if you qualify to let you know if an individual lawsuit or Unum class action lawsuit is best for you. [In general, Unum bad faith lawsuits are filed individually by each plaintiff and are not class actions.] Hurry — statutes of limitations may apply.

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