You receive a letter from your insurance company advising you that your disability claim is denied or terminated. After the initial shock wears off, here are the steps you should take to obtain your disability benefits.
Step 1 – Do not request an appeal before you collect all necessary paperwork for your claim.
All too often, one’s first reaction is to write their insurance provider telling them they have made a mistake and asking them to reconsider your claim. While you will eventually speak to your insurance provider about your claim denial, you must first take these additional steps.
Step 2 – Determine if your policy is covered by ERISA law.
If your disability policy is part of an employee benefit plan then it is probably governed by Federal Law known as the Employee Retirement Income Security Act (ERISA). Under ERISA, the insurer/Plan must give you 180 days following a termination or denial of benefits in which to request an administrative appeal or review of your claim. However, most Plans give you only one shot at an appeal. Thus, you must use the opportunity wisely.
Step 3 – Request a copy of your entire claim file from the insurance company.
When your disability insurance claim is denied your insurance company is obligated to provide to you, without cost, your complete claim file within 30 days of a written request. Once you receive the file you should go through and organize it in some fashion, i.e., putting all the medical records together segregated by provider and in chronological order. Once you have organzied the file it will be easier for you to see what is missing from the records. If the insurance company had your file reviewed by their own medical or vocational consultants, you will see their reports and have a better understanding of why they denied or terminated your claim.
Step 4 – Request a copy of your disability insurance plan or policy.
Having a copy of the Plan or disability policy is important. These documents are your contract for benefits and set forth all of your rights and obligations. You should be able to obtain the policy from the administrator of the Plan who is typically the employer. However, if there is a claims administrator then they will most likely be able to send that document to you.
Step 5 – Contact an attorney that specializes in representing individuals with ERISA claims.
An initial conference with an attorney should not cost you anything. However, make sure the attorney is experienced in handling ERISA benefit claims. The law applicable to these claims is unique and technical. If you have done your homework and have the claim file, the policy and your letter of denial, you should be able to answer many of the questions the attorney will have to help you evaluate your claim. You are most likely emotionally attached to your claim and getting input from an experienced attorney can often be enlightening. Remember, the fact that you are disabled does not guarantee that you will receive benefits. It does not matter how many times you tell the insurer that you are in pain and cannot work. What is important is the presentation of evidence that sets out your physical limitations associated with your illness or injury and how those limitations preclude you from performing the duties of a job.