Having to submit a long-term disability claim is never what anyone wants to do, but sometimes, it is what they have to do. After all if a disability prevents you from working, you need those benefits to survive, and it is why you purchased your long-term insurance in the first place. However, if you received a denial letter from your insurance company, you would want to know your options.
Review the denial letter
Review the denial letter to understand why your claim was denied as it must explain the basis for the denial, including the evidence that was used to deny your claim. Often, the claim is simply a lack of sufficient medical evidence or a failure to meet the definition of disability, which sometimes can both be rectified with more medical documentation. There could also be a citation to some treatment non-compliance, a pre-existing exclusion or limitation or some other policy exclusion or limitation.
Note your deadlines and the appeal and reconsideration instructions. You must follow these instructions and deadlines.
Request a copy of your claim file
Next to prepare for your appeal or reconsideration, request a copy of your claim file. This file will contain that information cited in the denial letter. This will include your application, medical records and reports, policy and coverage details, etc. This information will help you find inconsistencies, omissions, errors and additional information that you can provide to substantiate your claim.
Gather evidence and build your case
Once you find the inconsistencies, omissions or errors, gather the information to substantiate that these are in fact, inconsistencies, omissions or errors. If just additional information is needed, gather that information, like updated medical records and reports.
You may also need additional statements from your care providers, co-workers, family and friends to show how your disability affects your ability to work and perform daily activities. If there are new tests or results, include those as well. Before you submit your appeal, make sure you review your policy documents, the denial letter and your additional information to make sure you comply with your coverage and can substantiate why you are entitled to coverage.
Submitting your appeal
Depending on whether you have an individual or group plan, you likely have various levels of appeals and reconsideration. For individual plans, you can usually appeal directly to the insurance company, and then file a lawsuit if that appeal is denied. For group plans, there are usually one or more administrative appeals before you can file a Employee Retirement Income Security Act lawsuit.