Insurance claims denied or underpaid

Too sick to work, and told you're not disabled

Your doctor has said, in writing, that you can't do your job. You filed the claim, you sent the records, and the insurer's reviewer, a doctor who never met you, decided you can. Or the benefits were paid for a while and then stopped, often right around the time the policy's definition of disability changed.

Long-term disability claims are won and lost on paperwork, definitions and deadlines, and most of the work happens before anyone goes near a court. Here is how it usually runs when the coverage came through your job, and where we come in.

Tell us what happened

If the coverage came through work, a federal law sets the rules

Most disability insurance provided through an employer is governed by ERISA (the Employee Retirement Income Security Act), a federal law for the benefit plans employers provide. Federal rules under ERISA say what the insurer must tell you, how the appeal works and what you're entitled to see. Plans run by a government employer or a church are usually outside ERISA, and a policy you bought on your own follows your state's law instead, so the steps below may differ for you. If your claim was first made many years ago, a few of these protections may not apply to it.

What the denial letter has to tell you

Under those rules, a letter denying or stopping disability benefits must be written so you can understand it, and must include:

The specific reasons for the decision, and the policy terms it relies on.
What further information would help your claim, and why.
How to appeal, and the time limit for doing it.
Why the insurer disagreed with your own doctors, and with any Social Security disability decision you gave it.
That you can have a copy of your claim file free of charge.

The appeal inside the insurance company comes first

Before you can take an employer plan to court, you usually must use the plan's own appeal. Lawyers call this an administrative appeal: a written request asking the insurer to look at its decision again. The plan must give you a set period to file it, counted from the day you receive the denial letter, and for disability claims the federal rules set a minimum length for that period. Your letter states the plan's own deadline. Write down the day the letter arrived, and keep the envelope.

The plan can't charge you a fee to appeal, and it must let someone you choose, such as a lawyer, act for you.

Ask for everything the insurer used to decide

The claim file is every document, record and note the insurer relied on, considered or created while deciding your claim, including reports from doctors and job experts it hired. You're entitled to a copy free of charge if you ask. Ask in writing, keep a copy of your request, and note the date you sent it. Reading the file tells you what the appeal has to answer.

What a strong appeal usually contains

The person deciding the appeal must consider everything you send, even if it is new, and must not be the person who denied the claim or someone who reports to them. They may not simply defer to the first decision, and on a medical question the insurer must consult a qualified health professional who was not consulted the first time. If the insurer turns up new evidence or a new reason for denying you while the appeal is open, it must share it with you in time for you to respond.

In many cases, what is in the file when the appeal closes is all a court will later look at. So the appeal is usually the moment to put everything in:

Letters from your own doctors describing what you can and can't do: how long you can sit, stand or concentrate, and how often you would miss work, not only your diagnosis.
Test results and treatment records, answering the specific reasons the letter gives.
A description of what your job actually demanded, physically and mentally.
Statements from people who see you day to day.

What your policy means by disabled

Many policies define disability in two stages. At first you may count as disabled if you can't do your own occupation, the job you actually had. After a period set in the policy, they switch to a stricter test: whether you can do any occupation that fits your education, training and experience. Many claims are cut off at that switch, often with a report listing jobs the insurer says you could do. Read your policy's definitions, or have a lawyer read them with you.

After the appeal is decided

The insurer must decide the appeal within a set time, which it can extend once, in writing, for special circumstances. If it denies the appeal, the letter must tell you about your right to go to court and about any deadline in the plan for filing a lawsuit, including the calendar date that deadline runs out. Some plans count that deadline from an early point in the claim, so read it the day the letter comes.

If the insurer didn't follow these rules strictly, you may be able to go to court without waiting for the appeal to end, though some small slips that didn't harm you don't count. Nobody can promise how a claim ends: the insurer decides the appeal, and if it goes further, a court decides.

Many policies require you to apply for Social Security disability benefits and then reduce your monthly payment by what Social Security pays. The two use different definitions and different processes, and a denial from one doesn't decide the other.

Where we come in

You shouldn't have to fight an appeal on your own while you're too sick to work. If we take your case, we choose a firm that handles disability appeals regularly to lead it, from firms we have vetted for their expertise and track record, and we stay responsible for your case with them until it's over.

What helps to have ready

The denial or termination letter, with a note of the day it reached you.
The policy or certificate of coverage, and any plan papers from your employer.
The claim file, if you have asked for it, and the date you asked.
The names of your treating doctors and a list of your conditions and medications.
Your job description and a short note of what your work physically and mentally required.
Any Social Security disability application or decision.

Disability denial organizer
A printable page for the denial letter, your policy, medical records, letters with the insurer and a dated timeline.
Disability claim denied: what to gather first
The deadline, the claim file, the policy, your medical records and a dated timeline, gathered before the appeal is due.
What to have ready before you talk to a lawyer
A short, practical list you can use for any kind of problem.

Where we fit in

A lawyer at our firm looks at your case. If we take it and another firm is better placed to lead it day to day, we choose that firm from firms we have vetted for their expertise and track record, and we stay responsible for your case with them.

Questions people ask

The denial letter gives me a deadline to appeal. What if I miss it?

Missing it can end the claim, because a court usually expects you to have used the appeal first. If it's close, get help with the appeal now.

Should I write the appeal myself?

You can. But because the appeal may be the only record a court ever sees, it's worth getting help first. The strongest appeals usually answer each reason in the denial letter with new medical evidence aimed at it.

Can a lawyer get my benefits back?

No one can promise that. A lawyer can help you build the fullest file you can and make sure the insurer follows the rules. The insurer decides the appeal, and if the claim goes to court, the court decides.

My benefits were approved, but the amount seems wrong. Is that worth asking about?

Yes. Offsets for other income, how your pre-disability earnings were calculated, and claims that you were overpaid are all worth checking.

Treated unfairly at work
If your employer treated you unfairly because of your illness, or refused a reasonable change to your job.
Missed, late or wrong diagnosis
If the condition that disabled you was missed or caught late.

More about insurance claims denied or underpaid

This page explains things in general terms. It is not legal advice about your situation, and the law differs from state to state.