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The Administrative Appeal Stage for Long-Term Disability Claims

The Administrative Appeal Stage for Long-Term Disability Claims

The administrative appeal stage is a critical part of the long-term disability (LTD) claim process. It offers claimants a chance to challenge an insurance company’s denial of an initial claim—if one occurs. Insurance companies do closely review claims during this stage and may still issue a denial but understanding the administrative appeal stage and how to strengthen a claim that an insurer denied can raise the chances of success.

In this article, Chisholm Chisholm & Kilpatrick (CCK Law) will discuss:

  • What the administrative appeal stage is
  • Key steps claimants should know about the appeal process
  • Ways LTD claimants can strengthen their appeal
  • What to expect after filing an administrative appeal
Who We Are: Chisholm Chisholm & Kilpatrick is a nationally leading public interest law firm based in Providence, Rhode Island. Since 1999, we’ve been helping long-term disability claimants get the benefits they need through claim assistance, appeals, litigation, and education.

What Is the Administrative Appeal Stage?

The administrative appeal stage is typically the second phase of the LTD claim process. It takes place when claimants receive a denial of their initial claim and want to challenge that denial. This phase allows long-term disability claimants to submit a formal appeal and provide new or updated evidence that supports their claim.

How Long-Term Disability Administrative Appeals Work

Insurers often deny initial LTD claims. Some common reasons insurance companies deny initial claims include:

Additionally, administrative errors can result in wrongful denials. It is important to review the denial carefully and submit a strong appeal.

If their claim is governed by state law, claimants often can bypass the appeal stage and file a lawsuit if they choose. However, for various reasons, it can still be a good idea to file an appeal first anyway. In claims governed by ERISA—like those under most employer-issued LTD policies—claimants must file an appeal before filing a lawsuit.

An administrative appeal must be filed within a set time. This period is typically 180 days from the date of the denial. Missing this deadline can prevent a claimant from receiving benefits and/or seeking legal action. Therefore, it is vital to thoroughly read an LTD insurance policy and make special note of all filing deadlines.

Note: An insurance company may still deny an administrative appeal. In this scenario, you may wish to file a lawsuit. Litigation can be difficult, especially under ERISA. For more information, read our article on litigation and long-term disability insurance.

Key Steps in Filing an Administrative Appeal

Filing an administrative appeal for a long-term disability (LTD) claim involves several important steps that can significantly affect the outcome of a case. These steps include:

  • Review the denial letter. Carefully examine the insurance company’s claimed reasons for denying the claim.
  • Request a copy of your c-file. A claimant’s “c-file” is all the information their insurer has on them and their claim. Claimants have the right to this file in ERISA-governed claims, but they must request it—an insurance company will not just give it to them. This file can be exceptionally large, so it is important to request it early in the appeal process.
  • Collect and submit additional evidence. This may include updated medical records, any relevant correspondence, evaluations, vocational evidence, and reports from your doctors.
  • Write a comprehensive appeal letter. The letter should include all gathered evidence, directly address the reasons for the denial, and explain why the decision should be overturned.

How to Strengthen a Long-Term Disability Appeal

Submitting a strong administrative appeal is vital for claimants trying to overturn a long-term disability (LTD) denial. Taking specific steps can help build a stronger case and increase the chances of success.

Ways to strengthen a long-term disability appeal include:

  • Engage experts to bolster the claim. Depending on the insurance company’s reason for the denial, claimants should not rely solely on their own understanding of their condition. They should enlist medical professionals to provide detailed evaluations of their health and how it impacts their ability to perform their job. Vocational experts can further strengthen their case by objectively assessing how their disability affects their capacity to work in their specific field or any occupation. Their specialized knowledge can add credibility to the appeal and provide valuable insights for the insurance company’s review.
  • Proactively address common denial tactics. Claimants should familiarize themselves with the strategies insurance companies often employ to deny claims. This includes understanding how they might use surveillance, potentially biased medical reviews, or preexisting condition exclusions to justify their decisions. By anticipating these tactics, LTD claimants can prepare counterarguments with evidence and legal support to demonstrate the unfairness or inaccuracy of the insurer’s assessment.
  • Leverage ERISA rules for a fair review process (if applicable). If the Employee Retirement Income Security Act of 1974 (ERISA) governs their LTD claim, then claimants must understand how this federal law provides specific regulations to protect their rights. These rules ensure a fair and thorough review of the appeal, but insurance companies often take advantage of ERISA. Thus, claimants need to familiarize themselves with ERISA to hold the insurance company accountable for its actions.
  • Seek professional guidance from a Long-Term Disability Attorney. Navigating the complexities of a long-term disability appeal can be challenging. An experienced LTD lawyer can be an invaluable asset. They can guide you through the process, assist with gathering and presenting evidence, effectively counter denial tactics, and ensure that the claimant’s rights are being protected under ERISA. Their knowledge can improve a person’s chances of a successful appeal.

What to Expect After Filing an LTD Administrative Appeal

After filing an administrative appeal for a long-term disability (LTD) claim, it is important to know what to expect during the review process.

Disability Insurance Company Deadlines: Why They Matter For Your LTD Claim

The timeline for an appeal varies. Under ERISA, an insurance company must make a decision within 45 days. However, insurers can, under special circumstances, take a 45-day extension. In certain situations, tolling may be allowed.

Nonetheless, during this period, the insurance company will review the appeal. One of the most common things insurers do is have a doctor do a paper review of the claim. They may also conduct surveillance to monitor the claimants and find evidence that might contradict the claim.

Moreover, some insurers may require a claimant to attend an independent medical exam (IME). These evaluations are not always “independent” as the name implies. Rather, IMEs are typically administered by a doctor paid by the insurance company. As with surveillance, the insurance company is trying to find a reason to justify the issuance of a denial.

At the end of the process, the insurance company will either approve or deny the claim. In some cases, the insurer may ask for more information before making this final decision.

Receiving a denial of an administrative appeal can be stressful, but claimants do have options if their appeal is denied. Filing a lawsuit—both under ERISA and state law—is often the next step. Arbitration may also be an option.

It is crucial to keep track of the statute of limitations for legal action, as missing this deadline can prevent further action.

It is important to note that, under ERISA-governed claims, if an insurance company obtains new evidence during its appeal review and intends to deny the appeal on that basis, it must give the claimant an opportunity to review and respond to that new evidence prior to making the decision.

Call CCK Law Today for a Free Case Evaluation

If an insurance company denies your long-term disability claim, then you have the right to file an administrative appeal. CCK Law has over 25 years of experience helping LTD claimants with their appeals and may be able to help you, too. Call us today at (800) 544-9144 for a free case evaluation with a member of our team.