Complete Guide to ERISA Disability Appeals
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You were responsible and forward-thinking when you opted into your employer’s disability insurance policy, but you never thought you’d actually use it. Now, though, you’re sick or injured, unable to work and you need disability benefits, so you file a claim. And then you get a notification that your claim has been denied.
A disability insurance claim denial can be a devastating blow and feel like the end of the world, or at least the end of the road. But it doesn’t have to be. You can, and should, file an appeal.
The Employee Retirement Income Security Act of 1974 or, “ERISA,” governs benefits, like disability, health and life insurance plans, provided by your employer. Under this law, you have the right to appeal a decision by the insurance administrator – whether that is your employer or the insurance company – to deny a claim.
ERISA has a uniform system for the appeals process, which includes strict deadlines, instructions and guidelines for the submission of an appeal. The way this process is handled – from the adherence to deadlines to the quality of information submitted – is vital to the success of your claim because if the decision to deny is upheld by the insurance company and the case goes to trial, you are not permitted to submit any new evidence. In short, an ERISA disability insurance trial is based solely on the information submitted before and with the appeal.
Below we’ve outlined some information about the ERISA disability appeals process so you know what to expect if you’re considering filing an appeal. Because the process of preparing an appeal needs to be treated like preparation for trial, it is recommended that you hire an experienced ERISA disability attorney.
The whole process kicks off when you receive a letter of denial from the insurance company. The denial letter is required to include details about why coverage has been denied. This includes citing the specific policy provision on which the decision was made; letting you know if there is any additional material or information you can provide to make the claim valid; explaining how to file an appeal and advising you of your right to bring a subsequent lawsuit under ERISA.
Timeline and Deadlines
You have 180 days from the date on the denial letter to file an appeal. The insurance company then has 45 days from when they receive your appeal to make a decision, though they are allowed to take two 30-day extensions if they can show good cause for the extension request.
180 days might sound like a lot of time, but when you consider that you’re essentially preparing for an entire trial in that time, it is, in fact, very little time and why many people opt to hire an attorney who will know exactly what evidence will be helpful for your case and how to go about collecting it.
With most policies, you can file a lawsuit against the insurance company following a decision on the first appeal to uphold the denial, though some require you to file a second appeal before filing a lawsuit. The insurance company cannot require you to file more than two appeals.
Trial by Judge
If once you’ve exhausted all of your options through the appeals process, your coverage is still denied and you decide to file a lawsuit, it’s important to know that ERISA does not permit jury trials. Your trial will be presented only to a judge who will use the information in the administrative record to make his/her decision.
At this point, you’re no longer trying to prove a disability, but that the insurance company wrongfully and unreasonably denied your claim; this is good to keep in mind as you prepare for the initial appeal since you’ll want to include documentation in the administrative record that would set you up for success in proving the claim was unreasonably denied. An attorney with experience in ERISA disability appeals will know exactly what types of evidence will be most effective for both the appeal and any subsequent trial, based on your unique situation.
The Administrative Record
The administrative record – sometimes also called the claim file – contains all the information pertaining to your disability insurance claim that you think will convince an insurer to overturn a claim denial.
We can’t say it enough: the evidence contained in the administrative record is all a judge will consider should your case go to trial.
Each case is unique and, again, an attorney will help you determine what evidence will be most beneficial for your unique situation. That said, here are some examples of the information that is important to include:
- Medical records and reports.
- Opinion letters from your doctors about your restrictions and limitations.
- Medical research reports about your condition.
- The original denial letter and any other claim-related correspondence.
- Information about your job and its duties, like a job description from your employer and statement(s) from your employer and/or co-workers regarding their observations about your ability to perform.
- A functional capacity evaluation (see below for more information).
- A vocational expert evaluation (see below for more information).
- Your own testimony, in which you address each of the reasons the insurance company listed in their denial letter and lay out your arguments against them with references to evidence supporting your arguments.
In the event of a trial, the administrative record may also include any internal reports from the insurance company’s own reviewing physicians and vocational consultants.
The importance of letters of support
It’s important to not overlook the value letters of support add to your claim file. Of course you want a letter of support from your primary doctor, but you should also get letters from other medical professionals who can weigh in on your ability to work. Examples include your general physician (if he/she is not the one primarily treating you for your disability), specialists, chiropractors and physical therapists.
A letter of support from your former employer, if you can get one, is also extremely effective. You can also include any personnel documents that show your history of good performance up until your disability made you unable to work.
The importance of a functional capacity evaluation
A functional capacity evaluation (FCE) can help prove disability by providing objective evidence that your condition prevents you from doing your job. The evaluation is conducted by your doctor or, in some cases, a doctor provided by the insurance company. During the assessment, the doctor tests both your physical and non-physical abilities in a variety of areas, such as lifting, walking, sitting and standing, concentration and attention, endurance and logical thinking, among others.
The doctor will compare the results of the evaluation with the tasks listed in your job description, along with any witness testimony you provide that speaks to additional duties not listed in the job description. He/she will use all of this information to assess what level of work you’re able to do (heavy, medium, light, sedentary or none).
The FCE is also designed to evaluate whether you’re exaggerating or lying (“malingering” in official terms) about your condition.
The FCE not only proves your diagnosis but also shows exactly how you’re limited and how that prevents you from completing the tasks in your job description. This is so important to your case because courts have upheld that insurance company decisions to deny a claim based on a paper review by a doctor where other evidence, like a FCE, is unavailable.
The importance of a vocational expert
A vocational expert provides an expert opinion in a detailed report that explains why your condition prevents you from performing your job duties. In a nutshell, he/she takes all the other evidence in your file – medical records and reports, resume, job description – and analyzes it to show how it all adds up to your inability to complete your job.
While a vocational expert will review the job description provided by your employer, he/she will dig deeper by interviewing you and drawing on his/her own knowledge of your field in order to create a comprehensive list of job responsibilities that’s usually more thorough than your original job description.
The vocational expert will also conduct research from vocational resources and databases to help him/her analyze and backup the specific skills and abilities necessary to perform your job. He/she will use your medical data to show how you’re no longer able to perform tasks requiring the use of those skills due to your disability.
The vocational expert’s report goes deeper than a FCE, in part, because it analyzes skills the FCE doesn’t, like leadership or supervisory skills and stellar communication or mathematical skills.
A report from a vocational expert is critical to your case because it makes it difficult for the insurance company to misinterpret your resume or job description. A vocational expert’s final report will objectively, and in detail backed by data, show why your disability prevents you from performing specific responsibilities associated with your job.
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