Dealing with a chronic pain condition can be exhausting and all-consuming. Being denied disability benefits by your insurer only makes matters worse. If your benefits are denied, it is important for you to be familiar with the appeal process. This way, you will be able to submit an appeal quickly and efficiently so as to avoid undue delay. Your efforts should be spent on self- care and healing, not battling with your insurance company.
Under the Employee Retirement Income Security Act (ERISA), you have a legal right to appeal the denial of disability benefits. Unfortunately, the burden and responsibility of proving your claim becomes yours. It is crucial for you to create a record of documented evidence during the appeal in case litigation subsequently becomes necessary. This is because there is a high probability the only evidence a court will consider is that which you provided the insurance company during consideration of your appeal. Here are just a few things that will be helpful to know before submitting your appeal.
A simple place to begin would be to request your claim file and policy from your insurance carrier. A claim file consists of: all medical records, reviewed internal notes and memos, outside doctor reviews, surveillance video and any other information the insurance company used to make a decision on your claim.
In addition to the claim file, supplement your medical records with narrative statements from your treating physicians. Don’t rely upon your insurer to draw an accurate conclusion about your condition. Ask your doctor to thoroughly explain in writing how Rheumatoid Arthritis has impacted the quality of your daily living. This will create a clear picture of the difficulties you are having. Also, do not ignore the side-effects of the treatment of your disabilities, and how those impact your ability to work. Very often, what you do to treat your condition(s) can have just as much of an effect on your ability to get through a workday as the disease/injury itself. Make sure you and your doctors mention any medications or treatments and what side-effects they have.
Do not limit yourself to the written support from your main treating physician. Although you will likely have one main doctor who treats you for your disability, you might also have experienced referrals to other physicians for co-occurring complications. Use this information to your advantage. The more people you have explaining your limitations and restrictions, and how your life has been adversely impacted by your illness, the stronger your claim becomes.
Other than your doctor, who is qualified to say whether or not you can work? Your employer/former employer can certainly show the insurance company that something changed over time that is now causing your inability to work. Get written support from your employer, and ask for a copy of your personnel file. The idea is that this information will show a history of good performance reviews, with the only negatives coming in at the time after your diagnosis.
Keep the support coming! It is often difficult for those who don’t understand the mysterious nature of Rheumatoid Arthritis to identify with its many subjective symptoms. Get written statements from people in your personal life. While they may not be medical experts, a spouse, other family member, close friend, or former co-worker can all provide excellent insight into the struggles you face on a daily basis.
Make your appeal letter more of a cover letter, telling the insurance company why you disagree with their decision, and what information they will find in your appeal packet (the information mentioned above) that will change their minds. Remember, any information you leave out of your appeal may never be heard or considered by a court! Carefully consider all of the information you would like to include before sending through certified mail, fax or e-mail. If you can’t prove it, it never happened.
Please note that because every claim is unique, this is not a comprehensive list, merely a reminder of important materials for an appeal. Managing an appeal on your own can be risky if you are not physically or mentally capable. If the case becomes too complicated to handle on your own, you may want to seek out advice from a professional. Kantor & Kantor has a team of experts that work on a on a contingency fee basis, which means you only pay if we obtain a benefit for you. We understand the struggle of living with a chronic disease, and we are here to help. For questions about your long term disability claim, call (800) 446-7529.