S To Write A Successful Disability Appeal Letter
If your disability claims have been denied, you will usually still have the option to write an appeal letter to support your claims. After you have considered your options for the appeal and contacted your lawyer, it is crucial to understand how to put that letter together.
The reality of the situation is that very few of these appeals are taken seriously, even though they might seem promising. One of the most important things that play a part in their success though is the way they are written. Here are some steps you need to take in order to make sure yours will be successful.
Understand Why Your Claim Was Denied
As mentioned, the reasons why the SSA denied your claim will be detailed in their decision notice. As such, you need to carefully read their decision and understand why you were not approved for disability benefits. It will help you come up with a convincing argument for your case.
The SSA usually denies a disability claim due to either medical or non-medical reasons. But it can also be because of both. The notice will usually explain this in a clear and easy-to-understand manner.
Why Did Prudential Deny My Long
If you file a long-term disability claim and your claim is denied, you will likely receive a letter in the mail notifying you. It is imperative that you read and understand this denial letter, as it will not only contain important information on how to move forward with your appeal but may also include valuable information on why you were denied.
While there are fair reasons your initial claim can be denied, such as lack of evidence or not fully meeting your policys requirements, there are also ways Prudential may try to hinder your claim so they do not have to pay benefits. This might include using their own medical experts to evaluate your disability or keeping surveillance on you in the hopes of catching you doing something you claimed you could not, thus disproving your disability. Prudential may also make their policy requirements difficult and confusing, which can result in mistakes on initial claims or details that are overlooked and go unfulfilled.
Reasons your claim might have been denied by Prudential include:
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Know What Kinds Of Arguments Work
When writing your brief, keep in mind that the Appeals Council finds certain kinds of arguments more persuasive than others. What kinds of arguments work? Here are some of the best.
- The ALJ failed to explain what weight he or she gave to your treating doctor’s opinions. Social Security Administration regulations provide that an ALJ should weigh various factors in deciding how much weight to give a doctor’s medical opinions regarding your limitations, including whether they are consistent with the other evidence of record. The regulations state that the ALJ, in his or her decision, must provide “good reasons” for the weight assigned to these opinions. If the ALJ gives little weight to your doctor’s opinion, ignores the opinion entirely, or doesn’t explain the weight he or she gave to the opinion, you may have a good argument that your claim should be sent back to the hearing level.
- The ALJ didn’t obtain testimony from a vocational expert. If the ALJ decides that you’re not disabled at step 5 of the disability process, he or she must cite examples of specific occupations that you can perform, along with how many of those jobs exist in the U.S. This can be accomplished only through vocational expert testimony. If no VE testified at your hearing, but the ALJ found you disabled at step five, the Appeals Council may order the ALJ to hold a hearing with a vocational expert present.
Don’t Waste Time On Losing Arguments
Minor mistakes. Disability claimants sometimes devote too much attention to pointing out relatively minor errors and trivial arguments that, even if accepted, wouldn’t affect the outcome of the case. Better to focus your attention on the two or three most critical mistakes and ignore the rest.
Credibility. In the past, ALJs were entitled to a lot of leeway in evaluating the credibility of the claimant and any witnesses. Thus, the Appeals Council was virtually guaranteed to ignore arguments that the ALJ incorrectly assessed someone’s credibility. However, an ALJ who didn’t find certain testimony or evidence credible was still supposed to provide specific reasons for this, and failure to do so could be “reversible error.” In 2016, Social Security actually removed mentions of “credibility” from its regulations and rulings. Today, ALJs are instructed to concentrate on whether a claimant’s symptoms are consistent with objective medical evidence and their own statements. A judge’s decision must contain specific reasons for the weight given to the individual’s symptoms.
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When To Hire A Disability Lawyer
Since the deadline for filing an appeal is non-negotiable, its best to act quickly.
Hiring a lawyer to review your appeal letter before you submit it to the insurance company is a smart move.
Keep a couple things in mind when deciding when to hire a disability lawyer:
A lawyer might be able to spot other kinds of documents that you might not think of to support your appeal. Because of their experience handling years worth of long-term disability denials, an experienced lawyer can craft arguments in a way that are more compelling to the insurance company.
Unlike a personal injury claim, this isnt a negotiation process with a back-and-forth between you and the insurance company. Its a one-shot appeal, and then you have no choice but to go to court if you dont get the satisfaction you need.
Thats why calling a disability lawyer as soon as you receive a denial of your claim can be a huge help. They will know what to do and how to do it so you dont miss your chance to have your claim covered, and hopefully avoid going to court.
Claim Doesnt Meet The Definition Of Disability Under Your Policy
There are 2 types of disability policies.
- Own occupation: In this kind of long-term disability policy, youre considered disabled if youre unable to perform the tasks associated with your specific occupation.
- Any occupation: This type of policy defines a person with a disability as someone whos unable to perform the duties for any job.
Many policies will automatically transition from an own occupation plan to an any occupation plan after a person has been disabled for 24 months.
Some LTD policies have exclusions, like pre-existing medical conditions or impairments related to substance abuse. There are also conditions that cant be diagnosed through objective methods , but for which the diagnosis relies on the patients own description of symptoms . Those policies are often limited to 24 months of benefits.
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Schedule A Free Consultation
Mr. Ortiz is an experienced long-term disability attorney. He understands how to communicate with the insurance company, the procedural requirements of the appeals process, and what kind of medical evidence you should include with your appeal letter. Call for a free case evaluation or contact us online.
If your injury is the result of an accident or if you also have a claim with the Social Security Administration, and youre looking for an attorney who can do it all, you may be in luck. Mr. Ortiz also handles Social Security Disability claims nationwide and personal injury claims in the state of Florida.
Know The Deadline For Your Appeal
Deadlines are critical in any legal process. Missing a deadline can have serious consequences, from frustrating delays to forfeiture of your right to appeal. The deadline for filing a long term disability appeal should be included in the insurers denial of claim letter.
The deadlines for appealing a denial from a group disability insurance plan provided by your employer are set forth in the federal law known as ERISA, and most individual policies also follow ERISA rules. Under ERISA, you have 60 days to appeal the denial, and the insurer has 60 days to conduct a review, followed by another 60 days if necessary. The insurers review must be conducted by someone who has greater authority than the representative who originally denied the claim.
Be sure to set reminders to notify you of an approaching deadline. To avoid complications and delays, its best to submit your appeal as early as possible.
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Vague Reason For Long
Heres another example, where the reason for denial is vague. However, the reference to the Transferable Skills Assessment gives you something to focus on:
In a situation like this, there is a clue about how you could focus your appeal. If I were advising a client, I would ask for a copy of the Transferable Skills Assessment . Then, you can look for ways to show it was based on flawed information, faulty assumptions, or poor judgment.
You could also get your doctor to review the TSA and offer a critique.
Or you could review the TSA and write a statement pointing out all the factual errors or flawed assumptions within the report. Often these TSAs are done without consulting you, so they can be full of errors or factual mistakes.
Request A Copy Of Your Claim File
Your claim file contains every piece of information the insurance company used to evaluate your claim.
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Heres how to make a request for your claim file:
- Send a request directly to your claim administrator.
- Provide any claim numbers you have in your documents, and copy your request to any claims examiners included in your denial letter.
- Send your request by certified mail with return receipt or by fax with a confirmation so that you can prove that the insurance company received it.
- Keep a record of when you made the request, proof of receipt, and any follow-up requests.
- If you receive your claim file and believe there are documents missing, you can follow up with a specific request for that information.
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Request A Copy Of Your Disability Claim File
Along with requiring the insurance carrier to issue a denial letter explaining why your claim was denied, ERISA requires these carriers to provide claimants with a complete copy of their entire claim file. This copy must be provided at no charge and can range from hundreds to thousands of pages, including:
- The insurance carriers medical reviews
- All the disability claim forms you submitted
- All the medical records you submitted
- A copy of your long term disability insurance plan documents
- Any internal emails or notes created by the insurance carrier
- Any reports of video surveillance
After a claimant requests a copy of their claim file, the disability insurance carrier will begin to prepare it claimants generally should allow at least 30 days to receive this information.
Sending The Appeal Letter
Send the letter together with the required forms and documentary attachments to the address indicated in appeals instruction. The SSA also has an online platform where you can submit your appeal. But you can always submit them in person at any SSA office near you.
Remember that you need to submit a written appeal within 60 days of receiving the notice containing the SSAs decision.
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Provide An Overview Of Your Disability
Give enough background so that Service Canada understands how your symptoms developed and have worsened over time. If available, you can correct any inaccuracies Service Canada made when they first made a decision on your application. This doesnt have to be lengthy, but one or two paragraphs should be sufficient.
I was first diagnosed with arthritis 5 years ago, in September 2014. I continued working as a restaurant manager at the restaurant where I had been working at for over 8 years and received initial treatments from my doctor. However, the pain and swelling increased to the point that I had to leave my job in August 2015. At that point, I found it difficult to dress myself and manipulate small objects, like socks, buttons or zippers. Because work is important to me, I took a job as a cashier at a local Shoppers Drug Mart, but by June 2016 the stiffness in my joints had spread to my knees and feet. I am unable to stand for long periods of time, bend down or lift heavy goods as a result.
Disability Appeal Letter Template Samples
Assortment of disability appeal letter template that will flawlessly match your demands. When creating a formal or service letter, presentation style and format is essential to earning a great first impact. These templates provide superb examples of ways to structure such a letter, and also include sample material to serve as an overview to design.
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Long Term Disability Appeals: Tips For Filing
Long term disability insurance is designed to protect you against unforeseen illness or injury that may leave you unable to work. If you have filed your disability insurance claim and received an unfavorable decision, Sokolove Law may be able to help you take legal action.
Denial of your long term disability insurance claim is a setback with serious financial and emotional impacts.
Knowledge, persistence and patience are your strongest allies in fighting for and winning the compensation you may deserve. The following steps are offered as a general guide to a long term disability appeal. Keep in mind, however, that the appeals process varies somewhat among insurers, and denials are often based on technical issues rather than merit. Working with a long term disability attorney to handle your appeal or review your paperwork can help you avoid delays and costly errors.
Now That Your Claim Is Denied What Do You Do
The claim specialist calls you and says, Oh, well, you are entitled to an appeal, and if you just want to send me a note saying that, I appeal this decision, what we will do is we will review it all over again, and well fix it. Well make the problem right. To be honest with you, and in my experience, my response to their reply to you is, Yeah, right. Thats not whats going to happen.
Every time they deny you, they are saying that your claim is not compensable. You do not have enough information in their claim file for them to award you disability benefits. Even if you just send them an email that says, I appeal your denial, they dont have anything different. There is nothing different in their file for them to change their opinion or their denial on. What you have to do at this point in time is make sure that you do two things.
#1 Give them additional information that they didnt have before that compels them to change their mind.
#2 Tell them all the different ways they were wrong when they denied your claim in the first instance, and all the different ways that they violated the Employee Retirement Income Security Act when they denied you the first time. Maybe they copied and pasted the nurse disability consultants report and they put it into the denial letter. Copy and paste is never a full and fair review process.
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Writing Your Appeal Letter
As you have likely realized, filing a timely administrative appeal is an all-important first step. It involves writing a formal appeal letter and attaching any supporting documentation to it. Though insurers and their requirements vary, these letters should typically include:
- The reasons the insurance company cited for your wrongful denial
- Your specific coverage or policys language that support your disability claim, including all medical, financial, vocational, and legal case law that supports your position.
When writing your appeal letter, or even when simply documenting an appeal, consider attaching the following, even if it is not requested:
- Your medical condition. Your tone should not convey anger, but thoroughly lay out all the objective and subjective testing and how the restrictions prevent you from working.
- Specific reasons, with references to your policy where possible, why you believe your disability claim is covered and, therefore, your denial is wrongful.
- Contact information for you, your treating doctor, and any people who can validate your symptoms, limitations, and disability.
If you include only the information you included in your original disability claim, you will get the same bad result. Consider, consulting one of the seasoned, top-rated disability insurance appeal lawyers at DarrasLaw to discuss the types of additional documents you may choose to add to your appeal. These may include:
Legal Representation For Your Long Term Disability Appeal
Although based in Florida, the Ortiz Law Firm represents disability insurance claimants across the United States. If your long term disability claim has been wrongfully denied, delayed, or terminated and youd like to speak to an experienced long term disability attorney then contact us online or call us at to schedule a consultation. We can help you evaluate your claim to determine how to move forward with the long term disability insurance appeal process.
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All Ltd Policies Provide For At Least One And Often Two Levels Of Administrative Appeals And It Is Through The Appeals Process That Many Workers Eventually Receive Their Benefits
By Aaron Hotfelder, J.D., University of Missouri School of Law
If your initial claim for long-term disability benefits has been denied by your insurance company, you shouldn’t give up. All LTD policies provide for at least one, and often two, levels of administrative appeals, and it is through the appeals process that many workers eventually receive their benefits. While it might seem unlikely that the same insurance company that denied you initially will approve you on appeal, the appeals are evaluated by different claim units who sometimes disagree with the initial decision.
If your LTD plan is a group plan provided by your employer, you’re required under federal law to exhaust all your administrative appeals if you want to file a lawsuit against your insurance company in federal court. Even if you have an individual plan not governed by federal law, you should still exhaust all your administrative appeals. There’s no sense in passing up an opportunity to prevail on your case early in the process, without having to file a lawsuit.
Here are some things to keep in mind if you’re planning on appealing a denial of long-term disability.