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What Do You Do If Your Benefits Have Been Wrongly Denied?

If your benefits have been wrongly denied, in whole or in part, you have the right to appeal to the insurance company.  Most policies require that you appeal first to the insurance company before going to the court.  You likely have a limited time to appeal.  If you miss this appeal deadline, you may lose your rights.

You do not need a lawyer to file your appeal with the insurance company.  You have the option of handling your own appeal.  You must follow the rules of your own policy or plan.  Depending on the circumstance of your claim, this may involve requesting a copy of the claim file from the insurance company; requesting a copy of the plan-governing documents in writing from the plan administrator; gathering information from your medical providers that evidences the impairments that keep you from working; analyzing all of the documents collected to determine what additional information is needed to prove your claim; communicate with experts and identify additional testing needed to measure your impairments; gather any material  information that the insurance company told you was missing; analyze the insurance claim file to identify legal and factual errors made by the insurance company; analyze the claim file to identify procedural violations of ERISA committed by the insurance company; submit a personal statement explaining why you are disabled along with witness statements; draft an appeal letter explaining why you meet the terms for payment of benefits and why the insurance company’s decision was wrong.

As you can see, there is a lot of work to do to prepare your appeal properly, and a short time to do it.  Therefore, we recommend that you consult an experienced ERISA LTD attorney as soon as possible after receiving your adverse benefit determination.  Do not rely on your doctor, an insurance agent or even a lawyer who is not experienced in this complex area of the law.  Your appeal is a critical point in your claim.  Many times, particularly with an ERISA-governed LTD claim, your appeal will be the last time that you can submit evidence in support of your claim.  After you receive a final appeal denial, you may not be allowed to submit new evidence in court.