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Denied Disability: What to Do Next

Did you file a Short Term or Long Term Disability claim only to have it denied by the insurance company?  Or have you been receiving Short Term or Long-Term disability benefits and then the insurance company suddenly decides that you are no longer disabled under their rules?   As frustrating as all of this can be, you generally will have the right to appeal the denial, assuming you act quickly.  At The Law Office of Paul J. Dombeck, PLLC, we are committed to helping people secure their full and fair Short and/or Long-Term disability benefits. Our legal team wants to ensure that you have the knowledge and tools to protect your rights and interests. A proactive approach is key. In this article, our Phoenix long-term disability lawyer explains the most important things that you should know about what to do next if your claim is denied in Arizona. 

What to Do Next if Your Disability Claim is Denied in Arizona

Step #1: Preserve the Disability Denial Letter and Carefully Review the Language

A disability denial letter can be a serious disappointment. Indeed, when you receive a denial letter for a disability claim, your first instinct may be frustration or confusion. At the same time, it is crucial that you remember that while the insurance company is given a lot of discretion by the Courts, there is a risk to the insurance company that a court may consider that they have abused their discretion, and so you still have a chance of winning back the benefits if you act quickly and secure expert advice.  The denial letter provides valuable information about the reasons behind the decision made by the insurance company. Be sure to: 

  • Preserve a copy of your disability denial letter; 
  • Carefully review the language, including the reason for denial, and;
  • Check for any listed deadline to file an appeal. 

Of course, in most cases, disability denial letters are filled with a lot of complex and vague industry-specific jargon, or conversely, phrases that sound much more simplistic than they really are.   A Phoenix, AZ, disability attorney can help you review the denial letter and the claim file, and to understand what the insurance company is actually saying.  

Step #2: Get Your Disability Policy and Review the Appeals Process

If you are preparing to appeal a disability denial in Arizona, it is crucial that you have a full copy of your policy, and that you secure a copy of the complete Claim File (Administrative Record) from the Insurance Company.  Among other things, your policy (‘Plan’) will include comprehensive language about the terms and conditions of your coverage, the relevant deadlines, and the appeals process. As a general rule, the document can be obtained from your insurance company or your employer if your coverage is through work.  Most people who have this type of disability coverage get it through an employer or a spouse’s employer.  Notably, these policies are regulated by a federal law called the Employee Retirement Income Security Act (ERISA). With ERISA plans, there is generally a statutory 180-day deadline to submit an initial appeal for a short-term or long-term disability denial. 

After you receive the written claim denial, it is very important when requesting a copy of the LTD Plan and the Claim file from the insurance company, that you also let the insurance company know that you still have evidence for the appeal that you or your attorney will be submitting.  Otherwise the insurance company might misinterpret your request for Plan and file-copies as your entire appeal, and might try to hastily make a further and final decision against you. This point is crucial because you generally only get one chance to submit an appeal, and when you and your attorney are still trying to secure and look over the Claim file, you are really only at the beginning of what can be a tricky and involved process of assessing what further evidence and other approaches are needed.  So until you have the claim file it may be difficult to even know what responsive evidence you will need, let alone how to go about trying to secure it.        

Step #3: Consult With an Experienced Disability Appeal Lawyer in Arizona

Insurance companies put a lot of resources into protecting and promoting their own interests. They are on their side, not your side. You do not have to take on the big insurance companies in a disability appeal alone. And because of the complexity of the ERISA laws and disability standards with these types of claims, it is not at all advisable to take on the big insurance companies without an attorney.  The right legal advice can make the difference between a successful appeal and a continued and final claim denial. One of the best steps that you can take is to consult with an experienced disability attorney in Arizona as soon as possible after receiving a disability denial letter. 

An experienced Long Term Disability attorney will understand the intricacies of the appeal process and help you navigate the complicated legal landscape. Do not give up on your right to seek disability benefits. It is not uncommon for insurance companies to deny Short-term disability claims or long-term disability claims that turn out to be wholly valid. Even very small errors can lead to an initial denial of disability benefits. 

Step #4: Gather and Organize All Supplemental Supporting Evidence

If you are already preparing to appeal a Short-term disability denial or a Long-term disability denial in Arizona,  submitting the exact same application package with no additional information and no corrections is generally not the right option. With limited exceptions, an identical file is very likely to result in your disability benefits being turned down a second and final time. The good news is that you have the right to submit additional supporting evidence as part of your appeal. 

What evidence should you include? It depends on the specific circumstances of your case. As a general rule, you will want to address the reasoning that the insurance company included in its disability denial letter.   But also it is important to address what the insurance company did not address or said little about in their denial, which are subtleties that an experienced attorney will know.  Relevant evidence may include additional medical records, expert opinions, personal testimonies, or anything else that reinforces the legitimacy of your claim. For example, if your denial was due to insufficient medical or functional evidence, obtaining comprehensive records detailing your condition from your healthcare provider should be an essential part of your appeal.  

Because the insurance companies usually use their own hired medical and vocational reviewers to analyze and to approve or deny an STD or LTD Claim, it is often difficult for an LTD claimant and the claimant’s treating medical providers to understand what needs to be expressed to address the subtleties of the objections raised by the insurance company and especially the insurance company’s consultants.  This is another important reason why it is important to have the help of an experienced attorney. 

Step #5: File Your Disability Appeal

After consulting with a lawyer, and then gathering your evidence, it is time to file your appeal. A disability appeal must ultimately be submitted in a timely manner. If you wait too long to initiate your disability appeal in Arizona, your claim could be denied a second time, solely on procedural grounds, and that usually means that you will not be given another chance to appeal, either to the insurance company or to the Court.  So ensure that you follow the prescribed appeal process detailed in your disability policy to avoid any missteps. 

While an appeal should be thorough and detailed, the content and phrasing of the appeal may be more complex even than it seems.  This is where most claimant’s greatly benefit from the expertise of an attorney, because there are often many subtleties to the denial and appeal process that an unrepresented claimant will not understand.  One of the reasons for this is that under ERISA, the Short and  Long-Term Plans’ disability definitions greatly favors the interpretation of the insurance company over that of the claimant, and the laws that govern ERISA disability claims are considered complex even by the Court’s that sometimes review the denials and appeals.      

Notably, with ERISA disability policies, the first-level appeal is an administrative appeal. How does it work? An administrative appeal is an appeal directly to the insurance company. In effect, it is an opportunity to have the insurance company look at your claim a second time with all of the supplemental documents, records, and other evidence that you provided. If your claim is denied again by the insurance company, it may be a ‘final’ denial, because most insurance companies do not offer a second administrative appeal, leaving you only the option of seeking review by the Federal District Court if you want to pursue the claim.

Because of the complexity of the rules and laws that govern these ERISA Short and Long-Term disability claims, an experienced attorney will advocate preparing a thorough and detailed response while there is still sufficient time remaining in the claimant’s 180-day appeal time.  Many claimants that too hastily appeal without expert legal advice, and present only a portion of that evidence that the insurance company and the reviewing courts are really looking for, can quickly receive another ‘final’ denial by the insurance company.  And that can be very unfortunate as the reviewing Court will generally only look at evidence that made it into the claim file before the insurance company sends a ‘final’ denial of the claim.  When that happens it can be very difficult for the claimant to ever obtain a favorable outcome in the Courts.  So it is very important to seek attorney representation as early as possible after receiving your first Short or Long-Term Disability claim denial.         

Schedule a Confidential Case Review With a Top Phoenix, AZ Disability Denial Attorney Today

At The Law Office of Paul J. Dombeck, PLLC, our Phoenix long-term disability attorney is a strong advocate for the people who need help the most. Was your disability claim denied? We are here to help you take the next steps. Contact our law firm right away to set up a free, no strings attached consultation. From our legal office in Phoenix, we represent disabled individuals throughout Maricopa County, including in Mesa, Chandler, Scottsdale, Gilbert, Glendale, and Tempe. 

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