A long-term disability (LTD) denial can leave you in a difficult position as you’re coping with substantial health challenges. However, receiving a denial does not mean it’s the end of the claim. If you disagree with the insurer’s decision, you may have the opportunity to file a formal appeal.
If you’ve been injured during work in Washington DC, call our work injury attorneys for a free case evaluation to (202) 919-5453.
1. Read the Long-Term Disability Denial Letter Carefully
Start by reviewing the denial letter from the insurance company. This notice should tell you the main reasons your LTD claim was denied or terminated.
Common explanations include inadequate medical evidence or the insurer’s position that you can still perform your own occupation or another occupation, depending on the policy’s definition of disability. There may also be policy exclusions, benefit limitations, unanswered requests for information, or missing forms.
2. Determine Your Deadline to Appeal
Appeal deadlines for employer-sponsored LTD plans governed by ERISA are strict, commonly providing at least 180 days from the denial to act. The notice you received should state the precise timeline and requirements.
Private or independently-bought policies may use different rules or shorter deadlines. Missing the deadline set by your plan could make it extremely difficult or even impossible to get the denial reconsidered.
3. Request the Insurance Company’s Claim File
If your plan falls under ERISA, you generally have the right to request the complete file the insurer used in handling your case, free of charge. This claim file can include:
- Reviews from company doctors
- Reports from independent medical examiners
- Surveillance material
- Comments by vocational experts
- The insurer’s internal notes
- Statements from your medical providers
Go through these records carefully, since this collection shows what the insurer viewed and relied on to decide your claim.
4. Strengthen the Medical Evidence in Your Claim
To improve your chances in an LTD appeal, address the shortcomings or gaps the insurer cited in your denial. If your health has changed or treatment is ongoing, request updated medical records from all treating providers.
Ask your doctors or specialists for written opinions detailing how your condition affects your daily life and ability to work, and respond to comments or critiques made by the insurance company’s own physicians.
5. Show How Your Condition Prevents You From Working
Insurers want to see a clear link between your medical limitations and your actual job duties. An effective appeal spells out step-by-step how your injury or illness limits your ability to handle your specific responsibilities, such as lifting, moving around, remaining focused, reliable attendance, or working for a full shift.
6. Contact a Long-Term Disability Lawyer
Consulting an attorney early in the appeals process can be very helpful. A knowledgeable long-term disability lawyer can thoroughly review your denial letter, policy, and claim to spot any errors or inconsistencies in the insurance company’s reasoning.
A D.C. workers comp’ attorney’s experience can help you identify what new medical records, statements, or vocational evidence could strengthen your appeal, and ensure your response directly addresses the insurer’s concerns.
7. Submit a Complete Written Appeal
Once you’ve gathered the necessary medical and vocational records and addressed the reasons for the denial, you’re ready to submit your formal appeal in writing. Your appeal statement should clearly lay out your argument, referencing specific evidence and policy language to show why the insurer’s decision was incorrect.
Include copies of all supporting documents, updated medical opinions, and any additional evaluations that have not yet been considered.
If you’ve received a long-term disability denial in DC, legal guidance can make a major difference in the appeal process. To discuss your options before filing your administrative appeal, contact our office for an evaluation.