1. Demanding documents from the Insurance Company. We write the insurer demanding a copy of: the plan; the policy; the SPD; the claim file; all documents relied on by the insurer in denying the claim; any internal guidelines used by the insurer; the reports of all medical and vocational reviewers; audio or videotapes of the claimant; and notes of any telephone conversations.
2. Demanding Specific Reasons for Denial. By law the insurer is obligated to provide specific reasons for their denial. We write the insurer demanding that they provide us with a more specific description of the reasons for denial. Often the initial denial letter only states that there was insufficient objective evidence in support of your claim.
The clients I most often see are clients who were approved for benefits by the insurance company but shortly thereafter the plan terminates their benefits. The most common arguments raised by the plan are:
• * The Claimant’s medical condition has improved
• * The Claimant is not receiving adequate medical care
• * Surveillance by a private investigator found that Claimant is not disabled
The Claimant’s Medical Condition Has improved
The initial approval by the plan has legal significance.
In order to deny benefits at a later time the plan has to show a major change in circumstances. In McOsker v. Paul Revere Life Ins. Co., 279 F.3d 586 (8th Cir., 2002) The Court of appeals held:
Prior to the Supreme Court’s decision Black & Decker Disability Plan v. Nord, 538 U.S. 822, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003), the Ninth Circuit applied the treating physician rule in ERISA disability cases. SeeRegula v. Delta Family-Care Disability Survivorship Plan, 266 F.3d 1130 (9th Cir.2001), vacated, 539 U.S. 901, 123 S.Ct. 2267, 156 L.Ed.2d 109 (2003). Under this rule, the opinions of a claimant’s treating physician are given special deference and may be disregarded only for clear and convincing reasons based on substantial evidence in the record. In Nord, the Supreme Court rejected this rule, holding that ERISA and the Secretary of Labor’s regulations implementing the statute do not command plan administrators to credit the opinions of treating physicians over other evidence relevant to the claimant’s medical condition.Nord 538 U.S. at 825, Following the rejection of the treating physician rule in ERISA cases, planadministrators almost uniformly ignore the favorable decision by the SSA when denying applications for disability benefits under ERISA.
Do you need representation for LTD benefits
While the process described above is relatively straight forward , many claims are denied.
There are three primary reasons why your claim may be denied:
1. You misunderstand the policy language.
2. You are unable to overcome the “hired gun” experts hired by the insurance company to defeat your claim.
3. You are denied by the internal appeal process and need to file a law suit under ERISA.
The policy requires that you appeal the denial in 60 days. Many of my clients believed that the requirement is satisfied by a letter stating that they are dissatisfied with the decision. This kind of “appeal” rarely if ever leads to reversal of the decision. Hiring a lawyer after the second denial is a waste of time as the Court will not accept any material not previously provided to your insurance claim representative and your Court filing is doomed to fail.