Long-Term Disability Attorneys in Augusta GA Offers Tips for Applying for an LTD Appeal
When claims for long-term disability insurance benefits, which protect against illness or injury that causes inability to work, receive unfavorable dispositions, our disability attorneys in Augusta GA can help claimants take legal action.
Long-Term Disability Appeals
Denial of a long-term disability insurance claim can have serious emotional and financial consequences, but knowledge, patience, and persistence can sustain a legal battle for full and fair compensation. Disability attorneys in Augusta GA recommend eight steps as general guidance to successful long-term disability appeals. There are appeal process variations among insurers, who in any case are not reluctant to deny claims on technicalities rather than factual merits. Disability attorneys in Augusta GA help claimants avoid errors that cause unnecessary expenses and delays.
When Insurers Deny Claims
To notify claimants of denials, insurers must state in writing:
- The specific facts(s) or reason(s) for denial,
- The specific policy provision(s) requiring or supporting the decision,
- What information might validate the claim,
- An explanation of appeal procedure;
- A reminder of the right to legal action under the Employee Retirement Income Security Act (ERISA), and
- Any insurer rules, policies, or criteria as factors in the decision to deny.
Claimants should read such insurer notifications with care. If the language is vague or unclear, they should contact their claims representatives and request explanations. They should remember that a pleasant, courteous approach is most likely to get them the information they need. Depending on the outcome of this contact, they may want to ask more specific questions.
If necessary medical records are unavailable or incomplete:
- Specifically which records does the insurer have and which are missing?
- Is the insurer actively searching for certain records of tests or findings?
- Is any medical provider report illegible or incomplete?
If the insurer finds that a claimant can do work provided in the employer plan:
- Which occupation or job description does the insurer mean?
- Does the occupation or job description include actual claimant duties, or is it a general entry from an occupational handbook?
If the insurer says the claim for benefits lacks evidence, the claimant should ask what specific proof the insurer wants. If the insurer says there is no coverage for the claimed condition, the claimant should ask for the specific policy provision for the no-coverage decision.
Deadlines are all-important in all legal processes. A missed deadline alone can lose a claimant’s right to appeal. The filing deadline for an appeal from denial of a long-term disability claim should be part of the insurer’s notification of denial.
ERISA establishes the deadlines for appeals from denials under employer group disability insurance plans. Most, though not all, individual policies follow ERISA rules. ERISA provides for claimants 60 days for an appeal and for insurers 60 days plus an additional 60 days if necessary for a supervisory review by someone of authority higher than that of the individual who denied the claim.
Claimants should set reminders of approaching deadlines. To avoid complications and delays, it’s best to submit appeals as early as possible.
Claimants should treat every contact with their insurers as fact-finding investigations. Though they may feel angry or frustrated by denial of their claims, they should bear in mind that hostility and sarcasm are never helpful.
Before every contact, claimants should organize their thoughts and make some talking point notes, for they will keep cool more easily if well prepared. When writing to their insurers, they should read what they write aloud to listeners and ask for input before sending their messages. Claimants can vent their feelings with people they trust, but every contact with insurers should advance the claim process.
After discussing denials with their insurer long-term disability claims representatives, claimants should know what additional information to submit to clarify questions and resolve issues.
- Claimants should identify any physician notes, reports, or other statements the insurer says are missing.
- They should keep a journal of their symptoms, recording daily how they feel and how much pain or fatigue affects them.
- They should ask their doctors for detailed letters explaining why they cannot do their jobs and specifically challenging insurer denials of their claims.
- Claimants should ask for copies of any information from their personnel files about how their symptoms impair their work performance.
- They should request letters from their employers specifying all job duties they can’t do because of their disabilities.
- They should ask supervisors and coworkers for written statements of what they witnessed about how disabilities impaired their job performance.
After documentation is complete, a letter of appeal states the claimant’s case:
- It starts with a factual overview of the main points of the claimant’s position.
- It tells how the evidence shows the claimant as indeed disabled as defined by the insurance policy.
- It lists supporting documentation and explains how each document supports to appeal.
- It states the claimant’s intention to continue the appeal process until approval of the claim.
- It avoids personal opinions unproven by evidence.
- It makes no threats, serious or facetious. An indication of copies to an attorney and to the state government insurance regulator is enough to let the insurer know the claimant has backup.
- The appeal letter goes to the insurer by certified mail with return receipt as proof of delivery.
The claimant calls the insurer to confirm receipt of the appeal letter and to ask about the progress of the appeal. This call is a good occasion to remind the insurer of the claimant’s intent to continue the appeal process until the insurer pays the claim.
If the insurer rejects the long-term disability appeal, the claimant should present another appeal repeating the first six recommended steps with emphasis on the fourth, new information supporting arguments for reconsideration. If the claimant has proceeded without an attorney to this point, it may be a good time to contact disability attorneys in Augusta GA for a consultation and advice on long-term disability insurance denials.
Claimants who file complaints with their state government insurance regulators pending their second appeals lay groundwork for lawsuits if insurers deny their appeals again. Although the complaint may not induce an insurer to overrule its denial of the claim, claimants must exhaust all available administrative remedies before taking their claims to court, where insurers frequently raise failure to exhaust administrative remedies as an affirmative defense. Long-term disability policies not subject to ERISA may not require exhaustion of administrative remedies.
Claimants who exhaust the appeal process without approval of their claims should not surrender hope but should consult qualified disability attorneys in Augusta GA to advise them. If they decide to proceed farther, their attorneys can file lawsuits against the insurers for reversals of the denials of their claims.
Contact Our Long-Term Disability Attorneys in Augusta GA
Two highly experienced disability attorneys have combined resources to serve clients in the Augusta and Aiken areas of Georgia and South Carolina better. Charles Wilkinson has practiced in this area since 1974, and Andrew Magruder has worked on disability cases since 2000. They practice disability law almost exclusively, handling claims at all stages, including hearings and appeals. They care about their clients and give them all the help they need to present their cases for best results.
Disabling illnesses and injuries are horrors in themselves, but then the disability claims process can be overwhelming with its complicated and confusing rules and procedures. Long-term disability appeals must follow procedures established in employer summary plan descriptions. Experienced, knowledgeable Wilkinson & Magruder disability attorneys prepare appeals that never fail to comply with these procedures.
If an insurer denies an appeal, the claimant may appeal a second time, either through the insurer company or an ERISA regional office. The Employee Benefits Security Administration, a division of the United States Department of Labor, administers and enforces ERISA.
Employers who violate ERISA risk civil and criminal penalties. After claimants exhaust all administrative remedies under their employers’ plans, they may then file ERISA claims in federal courts. Courts assess damages case by case for
- Benefits improperly denied,
- Interest accrued while benefits were denied, and
- Attorney fees for prevailing plaintiffs.
Leave the paperwork and the headaches of bureaucratic confrontations to qualified long-term disability attorneys in Augusta GA. Contact Wilkinson & Magruder, LLP, at (706) 737-0771 now for a free case consultation and evaluation.