If you are appealing your long term disability because the insurance company has denied your benefits, you need the claim file. The claim file is everything that the insurance carrier of your disability policy has that pertains to your case. Depending on the insurance company and the specifics of your case, the claim file could include any of the following:
- Records of telephone conversations that you’ve had with the insurance company, including a summary of what was discussed
- Internal notes made by the insurance company about you
- Internal memos between employees of the insurance company about you
- Email correspondence
- Copies of written correspondence
- Your medical records
- Your medical bills
- Forms submitted by you or on your behalf about your claim
- Your actual long term disability insurance policy (or short term policy, if you have one)
- Notes or other correspondence from nurses or other medical professionals hired by the insurance company to advise them about your condition
- Advice from vocational experts hired by the insurance company to advise them about your claim
- Correspondence with your employer
- Activity log of steps taken in your case
- Record of dates, deadlines and other timeline details
It can easily be over several hundred pages long, and in some instances, can contain one thousand or more pages.
Can I Review my Insurance Claim File before I appeal my LTD Denial?
You have an absolute right to review your claim file under ERISA.
A very careful review of your claim file is a must before appealing your long term disability. The appeal that you submit needs to take into consideration the relevant pieces of information that are in your claim file. Preparing the appeal starts with detective work before you begin gathering evidence and start writing. The insurance claim file contains many of the clues that you will need so that they can be addressed one by one when you write your argument. Remember, your ERISA appeal is not just a letter written by you or by your doctor letting the insurance company know that you disagree with their decision. It should be a well thought out argument which attacks their reasoning behind the denial. That is why it is so important to analyze the claim file that the insurance company has on you.
How do I get my Disability Insurance Claim File?
The insurance company is not going to just send you the claim file automatically. They know that you need it but are hoping that you won’t ask them for it. Many people don’t, setting themselves up for losing the appeal. You have to ask for it. This is the very first thing that you should be doing after you receive the denial letter because it takes about 30 days to receive it. Under ERISA, you only have 180 days to file your appeal, and obtaining the file often takes one month off of the already short six months that you are given under the law. When you request the claim file, do not say anything else that the insurance company could confuse as being your appeal. For example, when you request your file, don’t give in to the temptation to include in your letter anything letting them know how you feel about their decision to deny your disability benefits. This would allow the insurance company to argue that they thought that was your appeal, possibly taking away your right for you to submit your actual appeal. Your letter should make clear that you are requesting your claim file and that your request is not your appeal, which you will be sending later.
The insurance company cannot charge you for your claim file. They are legally required under ERISA to provide it to you or to your attorney, for free.
What are the next steps after I request my long term disability claim file?
Since there are very strict deadlines under ERISA, you likely only have 180 days from the date that you receive your denial letter to file an appeal. Six months might sound like a long time, but it is not when you consider the amount of work that needs to be done to prepare a strong appeal. While you should request your claim file immediately after receiving your denial letter, do not wait until you receive it to start preparing for your appeal. The denial letter also will provide you with clues as to what needs to be done. This is often a good starting point.
Depending on your situation, it might be time to see your doctor or submit to any additional testing that may have been recommended by your health care provider. If you have recently seen a doctor or been to the hospital for the condition that is preventing you from returning to work, immediately request your updated medical records . This way you will have them ready to turn in with your appeal. Statements made by your doctor that are contained in the newer medical records should also give you the support that you need for not returning to work.
Appealing long term disability is complex and requires a lot of work. Insurance Disability Appeals are one area of the law where it is just not a good idea to try to represent yourself. There is a lot at stake and if you lose your appeal and have to sue, you are going to be stuck with the appeal that you submitted. No new evidence will be allowed in your court case, so you need to make sure that your appeal counts and is as strong as possible.
If you have a denial letter from the disability insurance company, you should strongly consider hiring a lawyer to take this on for you. For more information about the disability appeals process, request a copy of my free book. We are here to help and would be happy to review your denial letter for you at no cost.
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