“My ERISA Long Term Disability Claim Was Denied…What Now?”
After making the difficult decision to stop working, you contact your Long-Term Disability (LTD) carrier and follow their hundreds of steps in completing your application. You connected them with your doctor, provided medical records, and even gave a lengthy recorded-statement. After several weeks go by (with no pay coming in) you receive a 7-page denial letter stating that you don’t meet the carrier’s “definition” of disability.
After getting over the shock of the denial letter, you read it again to try and determine what you can do in response. This blog will explain what can be done in order to appeal your denied long-term disability benefits, and what an experienced San Diego LTD attorney can help you with.
What the Denying Insurance Company Must Provide You
If denied, there are requirements under ERISA that a disability plan must meet. The LTD carrier must inform you with the specific reasons for a denial of benefits and you are also entitled to a “full and fair review” of the denial by your plan’s administrator. The denial notice must include four things:
- The specific reason(s)for the denial;
- Detailed references to applicable provisions of the plan on which the decision to deny was based;
- A description of any additional information or material necessary to make your claim, and reasoning as to why that stated information is necessary; and,
- Pertinent instructions on what to do if you choose to submit your claim for review.
Exhaust Administrative Remedies
The first step to take after your claim is denied is to exhaust administrative remedies; meaning, appeal the denial in writing to the insurance carrier. It is very important to remember there is a limited time frame to appeal the decision — denied claimants have 180 days to appeal the decision and then the insurance carrier has 90 days to consider the appeal. This could mean a claimant goes over 270 days without income.
Seeking Social Security While Disabled
Oftentimes, an ERISA policy requires a claimant to file for Social Security Disability. If a disabled claimant chooses to seek social security to cover daily expenses and bills during disability, the insurer is typically able to deduct social security from the total amount it owes him/her. If a claimant chooses not to collect social security, the insurance carrier may argue that the claimant has breached a long term disability claim requirement – to apply for social security.
If Your Appeal is Denied
If you chose to appeal the decision, and your appeal is denied, you may have the right to file a civil lawsuit against the insurance company. According to ERISA, you have the right “to recover benefits due to [you] under the terms of [your] plan, to enforce [your] rights under the terms of the plan, or to clarify [your] rights to future benefits under the terms of the plan.”
This is the point where many people deicide to enlist the support of someone familiar with ERISA and disability law, if they haven’t done so already at the start of the process. Consumer Watchdog provides a California Patient’s Guide, which suggests consulting with an attorney:
“Bringing a case under ERISA for denial of benefits by your health plan can be a complex and lengthy endeavor. This type of case is generally not the kind that one should undertake without legal representation. If you do decide to represent yourself, you should obtain an attorney as your legal “coach.” There are many useful legal reference sources available in your local law library and on the Internet to help you understand the litigation process.” Consumer Watchdog.
There are many reasons why your ERISA claim can be denied by an insurance company. As mentioned before, ERISA claims can be time consuming, stressful, and arduous. This is why it is so important to have a knowledgeable advocate in your corner during this difficult time. An attorney who specializes in long-term disability cases can expedite the process and improve your chances of having a successful claim, so you can focus on the most important thing of the whole ordeal – getting your health under control and feeling better.
The author, Joshua Bonnici, is the managing attorney at BONNICI LAW GROUP, APC, who represents injured and disabled individuals fight for fair and just outcomes. Feel free to learn more and reach out for a free case evaluation HERE, firstname.lastname@example.org, or at: 619-259-5199.