Disability appeals

 
 

If your short or long term disability claim is denied, or your benefits are terminated, the first step to protect your rights is to file an “administrative appeal.”  Also, if ERISA law applies to your case, the appeal may be your last opportunity to give the insurance company important information.  Regardless, the disability appeal is your best chance to get crucial information to the disability insurance company. 


For example, if you’ve been seeing a specialist but the insurance company doesn’t have her records, if you don’t send them in during the appeal, you might not be able to use them later.  This is because ERISA cases are treated as “administrative appeals” and the judge rules based on the “closed administrative record.”  In other words, the judge decides whether you’re disabled based only on the information the disability insurance company had when it denied your claim.  So if you don’t send everything in, the judge won’t see it.


Writing your own appeal has many risks because you might leave out important information. 

  1. What’s the best way to address the disability insurance company’s reason for denying your claim?

  2. Did the disability insurance company have an “independent” medical review?  Do you need someone to analyze their review to make sure it was fair and accurate?

  3. Do you need to hire your own specialists?  If so, what specialty, and who?  How much will that cost?

  4. What weaknesses are there in the disability insurance company’s claim file that you can address? 

  5. Do you need new tests to support your disability claim?

  6. And how exactly do you file your appeal?  Not surprisingly, disability insurance companies probably won’t tell you the best way to appeal their denial and don’t want you to know everything you can include. 

With disability insurance companies, the deck is stacked against you.  So having an experienced disability and ERISA attorney like Patrick Mause help with your appeal can greatly increase your chances for success.


Once you file an appeal, the disability insurance company has a limited time to make a final decision.  However, the insurance company can (and usually does) tell you it needs additional time --- typically an extra 30 or 45 days.  During this time, the insurance company may send your records for a “paper only” review by a few “board certified” doctors.  Often, the insurance company will not have a doctor personally examine you, even if you offer to let them.  Not surprisingly, the doctors who do the “paper only” review often act as a rubber stamp for the insurance company; saying the denial is correct. 


Then, the disability insurance company might call you to say it’s denying your appeal, and it will also send you a letter explaining its decision.  For example, the insurance company might say: 


  1. “We had a board certified rheumatologist [or an orthopedic surgeon, neurologist, cardiologist, etc.] review your claim.  She reviewed all your medical records and noted that your doctor said you were ‘feeling better’ and your ‘medications seem to be working‘ on [some date].  Based on this review, we have concluded that you do not meet the plan definition of ‘totally disabled.’  Therefore, no further benefits are payable and our decision to deny your claim is upheld.”  


Once the insurance company issues its final denial, the  administrative appeal is likely complete.  This is why it’s so important to know what information you want to include. 


The next step is to protect your rights by filing a lawsuit.  Assuming your case is subject to ERISA, you would file a claim for your ERISA benefits.  If your case is not subject to ERISA, you would file a claim for breach of contract and, possibly, insurance bad faith.  Filing a lawsuit can be tricky, so it is often best to consult with an experienced attorney for help with your case.  If you would like to speak with a lawyer about your short or long term disability, ERISA, or other type of insurance case, contact Patrick Mause today to set up a Free Consultation. 


 

APpeals --- your best chance to give the disability insurance company

evidence of your disability

The appeal process is your best, and possibly your last chance to give the insurance company evidence proving you are disabled.  It is important to get this step right.  And it is important to know what kind of information to send them to best prove your claim.  


If you don’t give the insurance company all the information that can support your claim during the appeal, you might not be able to give them that information later. 


An experienced disability or ERISA lawyer can make a huge difference in protecting your rights.  Contact Patrick today if you have questions about how to appeal an insurance company’s denial of your disability claim. 

The information on this website is intended to be informational only and does not establish an attorney/client

relationship, nor is it meant to give or be legal advice for a specific matter.  Please do not email or fax information to

Patrick Mause without first speaking or meeting with him because the information will not establish an attorney/client

relationship and may not be kept confidential. Patrick Mause is a lawyer admitted to practice only in Arizona, the Arizona

District Courts, and the Ninth Circuit Court of Appeals.  His office is located at 290 North Meyer, Tucson, Arizona 85701.