insurance denials

Our appellate practice, where we deal with legal opinions and language, gives us an edge in the area of insurance policies and denials. Recently, a large plaintiffs’ firm hired us on as co-counsel in a case involving an insurance company’s denial of coverage regarding an accidental policy. The company filed for summary judgment that argued that it was well within its rights under the policy to deny coverage, and we were given the task of filing a response. After we filed the response, the case settled on very favorable terms to the plaintiffs’ firm’s client.

We handle insurance denial cases in several different areas. Long-Term Disability denials is one of them.

Common Reasons for Long-Term Disability Denials

While each case is unique, there are some common reasons that insurance carriers cite when they deny long-term disability benefits. Some reasons are:

  • Lack of Objective Findings. A claims reviewer may deny a claim on the ground that, although your are experiencing disabling pain, there are no objective findings to substantiate your disability.
  • Not Disabled From Your Occupation. A claims reviewer may deny your claim on the grounds that you are not disabled from working based upon the national definition of your job requirements.
  • Pre-Existing Condition. The insurance policy may contain a 12-month pre-existing condition waiting period.
  • Failure to Fulfill the Elimination Period. Most policies have requirements that a claimant be continuously disabled during an “elimination period” in order to be eligible for benefits.
  • Not Under the Care of a Doctor. Most policies require claimants to be under the regular care of a physician. This requirement is usually critical for success on an appeal of a denial.

Dos and Don’ts

After Filing a Claim for Long-term Care or Long-term Disability Benefits:

  • DO follow up quickly on any requests from your insurance company for additional information. Missed deadlines might cause you to lose out of benefits.
  • DON’T agree to an independent medical examination without checking your policy first. These exams are routinely used to deny claims and are often performed by physicians paid by the insurer.
  • DO keep copies of all letters you send or receive from your insurance company, and take detailed notes of every phone conversation you have with it.
  • DON’T talk about your claim or your disability online. The insurer will monitor public forums and social networking sites and use that information against you.

If Your Claim is Denied:

  • DO review your policy to make sure you are eligible under the terms of the contract – even if the insurer says you aren’t.
  • DO appeal your denial in writing. Each insurance policy typically contains detailed procedures governing the claim review or appeals process. With some policies, a simple letter is enough to begin the appeals process. However, the process can differ significantly depending on whether it is an individual policy or a claim subject to ERISA. If you don’t appeal or follow the process properly, you may not be able to reverse the denial.
  • DON’T give up. If you have a legitimate claim, use every means possible to receive the benefits that you may be entitled to.

Filing a Claim

Filing a Disability Claim: Understanding Your Policy

Before filing a long term disability claim, it’s important to have a basic understanding of your policy. Being educated about its terms and coverages will help you deal more confidently with the insurance company and recognize when you are being treated unfairly. Below are some basic factors you should be aware of prior to starting the claims process.

Do You Have a Private Disability Insurance Plan?

Disability insurance purchased from a private carrier—either directly or through your employer—should not be confused with Social Security Disability Insurance (SSDI). SSDI is a Federal program that covers disabled individuals (we don’t handle those claims). Private disability insurance is also different from workers’ compensation, which covers job-related injuries.

Do You Have Short-Term Disability Coverage or Long-Term Disability Coverage?

Short-term policies are designed to replace a portion of your income for disabilities lasting up to six months. Long-term disability insurance is more comprehensive, providing benefits for anywhere between five years up to the age of 65.

If you have a long-term disability plan that was provided as an employee benefit or purchased as an employment-related group plan, it’s probably governed by ERISA, a federal law regulating most non-governmental employee benefit plans. This law is to ensure that health and disability insurance plans are managed responsibly, but it is weighted towards the employer.

Do You Have a Qualifying Medical Condition?

Whether you can collect under your policy is determined by whether you have a qualifying medical condition. The list of qualifying conditions differs from insurer to insurer, and may include cancer, muscular disorders, autoimmune disorders, gastrointestinal diseases, and certain psychological conditions.

Once you’ve decided to file a claim for disability payments, follow the claims procedure that is laid out in your insurance policy. Remember that an insurance policy is a contract between you and the insurance carrier. It states that in exchange for your faithful payment of premiums, the insurer will pay you the benefits outlined in your policy if and when you need them. Not only should you expect to be able to collect the benefits you’re owed, you should expect that you will be treated with respect and honesty throughout the claims process.

Qualifications

Most people think that long term disability insurance is for people who have been physically injured in an accident and unable to work as a result of their injury. While this is true, it’s important to know that there are many medical conditions which may entitle you to receive disability payments from your insurer. These include chronic illnesses, neurological disorders, and certain degenerative diseases.

Some of the medical conditions that may qualify you for long term disability benefits include, but are not limited to:

  • Cancer
  • Crohn’s Disease
  • Chronic Fatigue Syndrome
  • Degenerative Disc Disease
  • HIV/AIDS
  • Lupus
  • Multiple Sclerosis

It’s the insurance company’s job to prove that you don’t qualify for long-term disability once you file a claim for it. Thus, it will ask for every detail of your condition, including lab tests, medical records, and other things in an effort to deny the claim. It may even misclassify your illness, putting it outside of coverage. Therefore, it’s imperative that you properly document everything about your illness.

Tips for Appealing a Denial

Denial of your long term disability insurance claim is a setback with serious financial and emotional implications, but it may not be the final word.

Knowledge, persistence and patience are your strongest allies in fighting for and winning the compensation you may deserve. The following steps are offered as a general guide to an appeal. Keep in mind, however, that the appeals process varies somewhat among insurers, and denials are often based on technical issues rather than merit. Working with an attorney to handle your appeal or review your paperwork can help you avoid delays and costly errors.

Step 1: Understand Why Your Claim Was Denied

To notify you that your claim has been denied, your insurer must send you a letter that covers the following points:

  • The specific reason(s) for the denial;
  • The specific policy provision on which the determination was made;
  • The information required to validate the claim;
  • The steps of the appeal process;
  • Your right to sue under ERISA (Employee Retirement Income Security Act); and
  • Any internal rules, guidelines or criteria that entered into the claims decision.

Read the letter carefully. If the language is vague or you don’t understand something, call the claims representative and ask for an explanation. Remember, your purpose at this point is to get information, and you’ll be more likely to get it if you’re pleasant and courteous.
++Depending on what you learn from the claims representative, you may want to follow up with more specific questions. For example:
If medical records regarding your condition are incomplete or missing:

  • Which records does the insurer have?
  • Specifically, what is missing?
  • Is the insurance company looking for certain lab tests or other clinical findings?
  • Was your doctor’s statement incomplete or lacking in detail?

If the insurer is questioning whether you are able to perform work described in the plan:

  • What occupation is the insurer referring to?
  • What job description is the insurer using?
  • Does the job description accurately reflect your actual duties? Or is it a generic job description pulled from an occupational handbook?

++If the insurer claims your request for benefits lacked sufficient proof about your symptoms:

  • Pain and fatigue are examples of subjective symptoms that may be difficult to prove. Ask the claims representative what kind of proof they’re looking for.

++If the insurer claims there was no coverage:

  • Ask for the specific policy provision on which the determination was made

Step 2. Know the Deadline(s) for Your Appeal

Deadlines are critical in any legal process. Missing a deadline can have serious consequences, from frustrating delays to forfeiture of your right to appeal. The deadline for filing an appeal should be included in the insurer’s denial of claim letter.
++The deadlines for appealing a denial from a group disability insurance plan provided by your employer are set forth in the federal law known as ERISA, and most (but not all) individual policies also follow ERISA rules. Under ERISA, you have 60 days to appeal the denial, and the insurer has 60 days to conduct a review, followed by another 60 days if necessary. The insurer’s review must be conducted by someone who has greater authority than the representative who originally denied the claim.
++Be sure to set reminders to notify you of an approaching deadline. To avoid complications and delays, it’s best to submit your appeal as early as possible.

Step 3. Stay Focused and Document All Contact with the Insurer

Try to approach every contact with your insurer as the fact-finding mission it is. Although you may feel angry or threatened by the denial of your claim—or frustrated because you’re one person fighting a big insurance company—hostility and sarcasm won’t help.

Before you call your insurance company, take a few minutes to gather your thoughts and make some notes. It will be easier to maintain a cool head if you’re well prepared. For written communication, read your email or letter aloud in the presence of a friend or family member and ask for their input before you send the message.

Remember – you can vent your frustration with a trusted friend or your spouse, but the goal of every communication with your insurer is to move the process forward.

Step 4. Gather New Supporting Information

After talking with your claims representative, you’ll probably know what kinds of additional information you must submit to answer questions and clarify details. Following are some examples of documentation that can help support your appeal.

Medical records
Start by identifying any doctors’ statements or other medical records the insurance company is missing.

  • If you haven’t been keeping a journal of your symptoms, now is a good time to start. Each day, record how you’re feeling and how your pain or fatigue affects your work. The journal can also be a valuable diagnostic and treatment-planning tool for your doctor.
  • Ask family members or friends to write their observations – as specific and detailed as possible – of how your symptoms have impacted your daily life.
  • If you and your insurer don’t already have one, ask your doctor to write a detailed letter explaining in medical terms why you are unable to perform your job. The letter should include specific challenges to the insurer’s denial of your claim, such as lab results or detailed progress notes.

Employment records

  • Ask your supervisor for copies of any notes in your personnel file that address how your symptoms have affected your work performance.
  • Request a letter from your employer detailing all the duties you perform in your job. Ask your employer to specify the tasks you can’t do because of your disability.
  • Ask your supervisor and coworkers to give a written account, as detailed and specific as possible, of how they saw your disability affect your performance.

Step 5. Write an Appeal Letter

After you’ve compiled your documentation, write a letter of appeal that states your case, point by point.

  • Write a brief overview of your position.
  • Tell how the evidence shows that you are indeed “disabled,” as defined by your insurance policy.
  • List the contents of your documentation packet and explain how each document you’re submitting applies to your appeal.
  • State that you are prepared to continue in the appeal process until your claim is approved.
  • Avoid personal attacks, opinions, or claims you can’t support with evidence. Keep your purpose in focus to move the process forward and get your claim approved.
  • Don’t make threats, serious or not. A simple cc: to your attorney and one to your state’s Department of Insurance or Insurance Commission is enough to let your insurer know you mean business.

Send the letter by overnight or certified mail with return receipt requested, and be sure to keep the proof of delivery.

Step 6. Follow Up

After a couple of weeks, call the insurer to make sure your letter was received and to ask how your appeal is progressing. This is a good time to remind the insurer that you intend to continue the appeal process until your claim is approved.

Step 7. If at First You Don’t Succeed…

If your appeal is denied, ask your insurer to consider another appeal. Then repeat the first six steps, with an emphasis on finding new information to change the insurer’s mind. If you haven’t worked with an attorney up to this point, this may be a good time to contact one for advice.

Filing a complaint with your state’s Insurance Department while your second appeal is under review will lay the groundwork for you to file a lawsuit if your appeal is again denied. Although your insurer may not reverse the denial of your claim as a result of your complaint, you are required to exhaust all administrative remedies before you file suit—should you fail to exhaust your administrative remedies, your suit could be dismissed. If your policy was purchased individually and is not subject to ERISA, you may not be required to exhaust administrative remedies before you sue.

Step 8. Take Your Claim to Court

Even if you’ve exhausted the appeals process and your claim hasn’t been approved, don’t give up hope. Consider consulting a qualified long term disability claims attorney who can advise you on your case. If you decide to proceed, your attorney can file a suit against your insurer in an attempt to have the denial of your claim overturned.

**Note that this page constitutes general advice and is subject to our legal disclaimers. Consult an attorney for legal advice for your specific case.

Homeowner’s Insurance

The vast majority of Americans have some kind of homeowners insurance. The amount and kinds of coverage available vary widely, and for that reason it is very important that when you make a claim, you understand what kind of coverage you have and that you actually read your policy.

We’ve seen many homeowners who have been taken advantage of by unscrupulous insurance adjusters when they make a claim. Coverage is denied based on dishonest “inspections” by companies hired for the sole purpose of determining that the cause of your loss was something that wasn’t covered by your policy. The insurance company may deny payment of the full amount owed, or insist that you use their cheap and poor quality repair people or contractors. These tactics are common and are used every single day to prevent homeowners from recovering what they are owed under their policies.

Something which will surprise most homeowners is that their policies typically provide coverage for damages caused by the negligence of the homeowner and his family-even when the accident which caused the injury is far from home. This coverage can be a life-saver when a homeowner gets sued. The coverage will provide that the insurance company has to provide an attorney to defend the lawsuit, and has to pay a certain amount of any judgment entered against the homeowner.

Fire Insurance

A fire at your home is a disaster even when nobody is hurt. Suddenly you have no place to stay, and often no clothes, no property, and no money.

Fire insurance is supposed to help with all of that, as well as getting your home rebuilt.

Unfortunately, some fire insurance companies are dishonest. They delay your claim. They come up with ridiculous reasons for not paying what they owe, for not repairing damage, and even for not paying at all.

All too often, they will claim that an innocent homeowner burned his own house in an attempt to avoid paying fire insurance claims.