When Appealing Denied Benefits

Denied Disability Benefits? Don’t Waste Your Chance to Appeal!

If you need a lawyer to help you file a disability claim or appeal, contact our skilled legal team at Edelstein Martin & Nelson. We have helped clients throughout the nation suffering from a broad spectrum of disabilities secure the benefits they need.

Obtaining disability insurance by filing a claim should be straightforward; however, this is not always the case. Insurance providers have been known to utilize questionable tactics to confuse or mislead claimants and then issue a complete denial of benefits for those who genuinely need them.

Are you applying for disability benefits that have recently been denied? Unfortunately, being denied benefits by the disability insurance company is common. In fact, in most states, denials occur in over 50% of first-time attempts made by claimants.

Ask a disability insurance lawyer from Edelstein, Martin & Nelson for help if this has happened to you. Our disability insurance attorneys have been helping individuals get disability insurance for decades and will stop at nothing to help you get the coverage you need. You can reach our office by calling 215-731-9900 for a free initial consultation.

Defining Disability Insurance

Disability insurance provides you with financial relief if you suffer an injury or illness that renders you unable to work. This type of insurance is important because a long-term illness or a disabling incident or accident will likely rob you of your financial stability if you are not covered.

To look out for your best interests and that of your family members, especially if your family depends on you for income, you should have disability insurance. A disability insurance attorney from the law office of Edelstein, Martin, & Nelson can help you file a claim for benefits, or help you file an appeal for a denied claim.

You May Be Legally Entitled to Disability Benefits

Any individual who has suffered a disabling illness or injury may be eligible for disability coverage. It is important to know that eligibility requirements may vary depending on the specific insurance policy you are covered by and/or the jurisdiction in which you are working. If you think you may be entitled to disability benefits, contact our firm for guidance.

• If you are suffering from a serious injury or illness: If you are suffering from a severe illness or injury that is preventing you from successfully performing the vital duties of your profession, you may qualify for disability benefits. Conditions that may render you able to collect disability benefits include long-term illnesses, musculoskeletal disorders, neurological disorders, or mental health issues as well as many others.
• When you have been hurt in a serious or debilitating accident: A car accident or a fall that resulted in substantial mental or physical dysfunction are examples of injury-causing accidents that may qualify you for disability benefits. It is important to note that the validity of your disability claim depends on the disability insurance laws in your particular state, the details of your policy, if you have a private or employer-sponsored one, and the extent of your disability. A disability insurance lawyer will be able to help you learn more about your specific situation.
• Suffering from a disabling mental health condition: You may be suffering from a serious mental health condition that is keeping you from being able to safely and successfully perform the tasks and duties of your job. Mental ailments such as severe anxiety, depression, or post-traumatic stress disorder (PTSD) often substantially affect individuals and their ability to operate normally in their everyday lives, including their jobs. Some people with demanding professions may end up dealing with these problems due to the extremely stressful nature of their jobs and the specific duties they entail.
• If you have suffered from substance use issues: Possibly related to the stressful and overwhelming nature of your profession, you may have suffered from addiction issues and/or substance use disorders as an attempt to cope. Sadly, problems like this may have had a detrimental effect on your ability to competently do your job. If your addiction has affected your ability to work, you may be eligible for disability insurance.
• Occupational hazards: If you work in high-risk environments where you are exposed to occupational hazards like toxic substances or radiation, it may lead to conditions or illnesses that are particularly disabling. This may qualify you for disability insurance.

Appealing a Denied Disability Claim

According to page 6 of the informational booklet on filing a claim for your disability benefits provided by the United States Department of Labor, claimants may experience denials for various reasons. You may simply be ineligible for benefits at this time, or, more commonly, your claim just needs more information about your disabling condition and the effect it has had on your ability to work.

Despite the reason for the denial, the Department of Labor states that you have at least 180 days to file an appeal from the date of your denial. If you are filing through your employer-based disability coverage, your employer may provide you with a different period of time in which to file. It could also be different if you have private disability insurance, so always check your policy.

In preparing your appeal to the federal government, you should make sure to reference the information provided in your claim denial notice, especially any further evidence you would like considered that relates to the reason for denial. Submit your appeal to the individual specified in your denial letter before 180 days has passed since you received your denial.

With the help of a skilled disability insurance attorney, you have a better chance of being able to successfully file an appeal and get the benefits you are entitled to.

Types of Disability Coverage

It is critical to keep in mind that every disability insurance policy is different with distinct waiting periods, exclusions, and benefit amounts. Therefore, it is important to familiarize yourself with the details of your particular policy to establish the precise requirements and circumstances under which you may qualify for coverage. Consulting with a disability insurance lawyer like those from the law office of Edelstein, Martin, & Nelson is definitely in your best interest if you wish to receive full and fair coverage. Let’s go over some of the types of disability coverage available.

Short-Term Disability

Generally, a short-term disability policy will begin providing you with payments as soon as your disability becomes apparent. Short-term policies usually pay for a maximum period of 3-12 months. These policies are usually provided by employers to their employees.

Short-term benefits usually apply to conditions or illnesses that temporarily prevent you from working. The distinct conditions covered may differ depending on the insurance policy in question. However, some common types of conditions where short-term benefits are applicable include injuries like sprains, fractures, concussions, or other injuries that require time spent away from work to recover but will not be permanent.

Some surgeries and medical procedures may require a short-term leave from work. Also, childbirth and pregnancy may be covered by short-term disability benefits for some individuals.

It is vital to thoroughly assess the particular conditions and terms of your short-term disability policy to fully comprehend the conditions covered, benefit durations, and waiting periods, as they often vary.

Long-Term Disability Benefits

Many employers offer employee compensation packages that include group disability coverage. These packages often include long-term disability insurance for their workers who are unable to work due to a serious injury or illness. Long-term disability insurance will come into play when short-term disability benefits expire, depending on the length of the policy.

Insurance companies estimate that one in seven individuals will develop a disabling condition at some point in their life. While many may think their disability will more likely occur due to a sudden traumatic incident, medical illness is more common.

Long-term disability (LTD) benefits are designed to provide you with income replacement for the duration of your expected working life when you become disabled and are unable to return to work for a prolonged period. LTD benefits preserve your financial health by providing you with a certain portion of your previous income when you are no longer able to work due to your disability.

ERISA Law May Cause Denials to Occur

Many disability policies provided by employers are regulated by a federal law referred to as the Employee Retirement Income Security Act of 1974. This law is more commonly known as ERISA.

Due to the complexity of ERISA, disabled individuals may experience denials of benefits due to incomplete documentation of their disabling condition or application errors. Others may be denied benefits due to administrators who claim that the disability suffered by the applicant is not covered by their particular policy. While ERISA was said to have been put in place to protect workers who become disabled, it often seems to make it harder for them to get approval for their claims.

If your long-term disability claim has recently been denied, you may still have the option to receive benefits when you file an appeal. However, if your appeal is mishandled, you may be permanently barred from receiving benefits for your disability. Too frequently, individuals who are denied benefits end up waiting too long to seek help, causing them to miss out on their opportunity to file an appeal. Others may try to handle the appeals process alone, resulting in being barred from receiving benefits when their appeals are unsuccessful.

How a Lawyer can Help You Appeal your Denial

To successfully safeguard your chances of having your claim approved upon appeal, you should contact an ERISA disability lawyer as soon as you can after you received notification of your denial. Because an appeal can be laborious and resource-intensive, it is critical to take prompt action following your denial. This can help to ensure that your potential for receiving full and fair disability benefits is not lost.

An attorney who is extensively proficient in handling long-term disability claims with a thorough understanding of the ERISA laws can help manage the appeals process and ensure you provide complete and accurate documentation for your appeal.

Moreover, when you have to communicate with policy administrators, having a disability attorney on your side can be extremely beneficial. Since administrators generally know a lot more about ERISA law than policyholders, it will put you at a significant disadvantage if you attempt to handle your claim by yourself without experienced legal representation. A well-seasoned ERISA disability lawyer can help rectify this inequity and help you secure the benefits you need during this difficult time in your life.

Reasons Your Claim May Initially Be Denied

Here are a few generalized scenarios in which your claim may be denied initially:

1. Inadequate Medical Evidence: To successfully support the fact that you are unable to work due to your disability, you must be able to show valid medical evidence of your diagnosis and treatment. If the documentation you provide does not adequately demonstrate the gravity of your disability, your claim may be denied.
2. Disability Definition Disputes: Policies provided by disability insurance companies possess specific definitions of disability that must be met for you to receive benefits. Your insurance company may attempt to dispute your interpretation of their definition of disability and whether your specific condition meets the standards for disability benefits.
3. Failure to Meet Waiting/Elimination Periods: Disability policies usually have waiting/elimination periods that must transpire before you can receive disability benefits. These waiting periods are usually put in place to distinguish the need between short-term disabilities and long-term disabilities, manage risk/costs, reduce fraudulent claims, and ensure the stability of your policy.
4. Pre-existing Conditions: Some policies have limitations or exclusions for pre-existing conditions. If your disability stems from a pre-existing condition existing within the exclusionary period of the condition, your claim may be denied.
5. Insufficient Documentation of Work Records: Your insurance company may require you to provide evidence of your work restrictions and limitations that prevent you from performing your regular tasks and duties. If the documentation you provide improperly demonstrates these limitations, you may experience a claim denial.

It is important to remember that if your claim does get denied, you have the chance to appeal this denial. If you’re able to provide additional evidence and present your case with the help of a disability insurance lawyer, such as an attorney from Edelstein, Martin & Nelson, it may increase your chances of being able to receive full and fair disability benefits in the future.

Should You Hire a Disability Lawyer?

Especially if you have recently been denied benefits, a disability lawyer can help you file a proper and complete appeal and get the coverage you need and deserve. The decision to hire a disability attorney is a personal choice that depends on your specific needs and situation. Some factors to consider include:

1. The complexity of your case: If your disability claim entails complex legal issues, denials, or if you anticipate difficulties during the application or appeals process, a disability attorney can provide you with valuable guidance and expertise.
2. Understanding of disability laws: Disability lawyers focus on disability law and deeply understand the legal regulations, framework, and requirements associated with disability claims. They can pilot the legal process for you, ensuring the protection of your rights.
3. Maximizing your chances of success: Disability lawyers are experienced in creating solid cases and presenting valid evidence that fully supports your claim. They will help you gather medical records, obtain expert opinions, and favorably present your case, providing you with the potential to increase your chances of a successful resolution.
4. Advocacy and representation: A disability attorney can serve as your advocate and representative throughout the whole claims and/or appeals process. They can correspond with the insurance company, handle clerical tasks, and attend appeals/hearings on your behalf, alleviating the stress and burden for you.
5. Contingency fee arrangements: Many disability attorneys work on a contingency fee basis, meaning they only receive a payment if they win approval for your case. This fee is typically a percentage of the retroactive benefits you receive, so you don’t have to pay out-of-pocket.