Why You Should Never Appeal Your Long-Term Disability Denial Without an Attorney

Why You Should Never Appeal Your Long-Term Disability Denial Without an Attorney

From time to time, I get a phone call from an individual that has independently completed the long-term disability appeal process and had their denial of benefits sustained by the insurer. They would now like to pursue the final step, which is a lawsuit. However, at this point, there is nothing I can do to help their case, often leaving the caller feeling overwhelmed and duped by their insurer.

This person will generally have done one, or all, of the following on appeal:

• Wrote a letter to the insurer regarding why they think they are “disabled” and should get benefits
• Convinced their doctor(s) to write a narrative on why this person is “disabled”
• Updated their medical records and sent them to the insurer

Supplying these forms of limited evidence is the incorrect method of pursuing an appeal. Below are a few reasons why this method may have resulted in a denied appeal, and why you should always hire a long-term disability attorney prior to filing an appeal.

The ERISA Process Requires Total Evidence From The Start

Appeals of an employer-provided long-term disability plan decision are covered under the Employee Retirement Income Security Act (ERISA). Under ERISA, the insurer must have an internal appeal process that the insured must exhaust before filing a lawsuit. A federal court’s review of the plan’s decision will ordinarily be limited to the evidence available to the plan administrator at the time that their final determination was made. This is why all supportive evidence of the case must be submitted to the plan during the initial appeal process, or else this evidence will not be considered in a lawsuit.

Limited discovery may be allowed in certain ERISA claims where a conflict of interest applies.
When the entity that administers the plan both determines whether an employee is eligible for benefits and pays benefits out of its own pocket, additional discovery may be allowed to weigh the conflict of interest.

Insurers Are Working Against You

Insurers typically do not work in your favor when you apply for an appeal. On appeal, the insurer will submit all the medical evidence to a third-party doctor who specifically will come to a medical opinion as to the claimant’s physical and/or mental restrictions.

It should not shock you that these doctors (paid by the insurer, usually indirectly, to avoid the appearance of a conflict of interest) rarely come to the opinion that the insured has restrictions that limit them from their occupation. The insurer often then sends this doctor’s opinion to an occupational expert, who finds there are jobs in the economy that the claimant can achieve with these restrictions.

Put yourself in the shoes of the federal judge that would be deciding this case: you have the very general, non-specific opinion of the claimant or the claimant’s doctor on why they are “disabled” versus the very specific opinion obtained by the insurer in regard to physical and mental restrictions and why an occupation remains feasible even with the restrictions.

Further, long-term disability plans generally define disability as the inability to achieve the major functions of the claimant’s own occupation for the first two years and major functions of any occupation for the years following. Likewise, while state law prohibits it, many national policies mandate the court may only review the plan’s decision for “abuse of discretion,” meaning that the judge wishing to overturn a denial must not only be convinced that the insurance company was wrong to deny the claim, but that the insurance company’s decision was so outrageous that it abused its discretion in denying the claim. That is a difficult standard to overcome, even if the claimant has a solid claim for benefits.

Work With An Experienced Lawyer From The Start

An attorney experienced in long-term disability appeals will build a record of all types of evidence (i.e., affidavits, expert opinions, diagnostics) relevant to the claimant’s physical and/or mental restrictions and how these restrictions preclude the claimant from achieving major job functions. This way, you will have substantial evidence ready for your appeal.

Furthermore, non-exertional limitations are often outright ignored by insurers and missed by attorneys not experienced with disability matters. For example, if a claimant needs a number of breaks or days off, this may be considered job preclusive. An experienced disability attorney will take these limitations into special consideration.

Our Experienced Attorneys Can Help

If you find yourself in the position of having your long-term disability application denied or your benefits terminated, please do not hesitate to contact The Schipper Law Group or call us at (248) 729-2414. We have assisted hundreds of clients in getting the benefits they deserve and would be happy to help you.