Long-Term Disability: How to Appeal a Claim Denial
Why are long-term disability benefits so important? If you become unable to work for a long period of time, disability insurance protects you from being without livable income. Employees in the United States are protected from denial of employer-provided disability benefits, so if your disability claim was denied, appealing can help you get the coverage you need. Here are some other important things to know about long-term disability benefits, including how to appeal a denied claim.
How does Wisconsin Long-Term Disability Work?
Long-term disability starts where short-term disability ends. These benefits help supplement income in the event an employee becomes physically unable to work as the result of an illness or injury. Conditions that typically qualify for disability benefits include cancer, severe back injuries, loss of eyesight, and worsening heart disease.
Both short-term and long-term coverage typically replace around 50-70% of an individual’s salary for a certain amount of time: usually 90-190 days for short-term coverage and 2-10 years for long-term. Although sometimes, long-term coverage can extend until the employee reaches retirement (ages 65+). It’s important to note that the benefit amount is based on the salary at time of policy purchase. Employees should update their plan accordingly as salary increases.
Why Do Claims Get Denied?
The most common reasons for claim denial are lack of evidence, missed appeal deadlines, and pre-existing conditions. Lack of evidence denials arise when a condition does not have “concrete” proof. For example, fibromyalgia causes long-term pain but does not show up on tests like X-rays or MRIs.
If a claim is denied, insurers must provide a letter outlining the following:
- Policy provisions on which the determination was made
- Reason for denial
- Any internal rules, guidelines, criteria that entered the determination
- The information necessary to validate the claim
- The steps in the appeal process
- A notification of the employee’s right to sue under the Employee Retirement Income Security Act (ERISA).
The appeal deadline can vary based on policy but is typically 60 days after initial denial. Having an experienced employment law attorney on your side is recommended for getting the appeal submitted correctly.
How To Appeal a Denied Claim
To start the appeal process, call the claims representative and learn what was missing from the initial request. From there, you’ll need to start gathering evidence to support the claim. This can include pulling additional medical records, recording pain and limitations, and having a doctor write a letter detailing the condition and its impact on work.
The next step is the send the insurer an appeal letter. This must include an overview of the job and its duties, additional evidence collected, and an explanation of how the new evidence supports the claim, proves disability, and rebuts the original denial.
After that, continue to follow up with the insurer. Check in with the insurer to make sure they received the letter and ask for the status of the claim in the appeal process.?The insurers decision should come in about 45 days. If the appeal is rejected, start over and find out what the initial appeal lacked. While filing a second appeal, file a complaint with the Wisconsin Office of the Commissioner of Insurance (OCI).?This is needed to be able to sue.
These cases are very complex and you’re going to want an expert on your side if you hope to be successful. If you believe your employee benefit rights have been violated, contact Walcheske & Luzi to talk with an attorney that exclusively concentrates on employee benefits law today.