When long term disability claims are denied, there is usually an option to appeal. At first, an appeal may seem promising. In practice, however, very few appeals are successful. This is likely because appeals are not to a neutral independent decision maker who will fairly and objectively assess the claim, but rather to the same company that denied the claim in the first place. In many cases, the person who conducts the appeal is the same person who denied, or is a colleague that sits a few desks away. But don’t give up! Some appeals are successful, and there are other options to consider if the appeal is denied.
Before writing an appeal letter, you should first consider when it is appropriate to appeal, and also whether to contact a long term disability lawyer before appealing. If you do decide to appeal on your own, follow the tips below.
When to Appeal
There are two exceptions to the general rule that long term disability appeals are unlikely to succeed.
The first is where there is compelling new evidence that has not already been provided to the insurance company. An example would be where the family doctor submits the initial application, at which time you had not yet seen a specialist. If you now have a specialist who supports disability, a report from the second doctor might result in a successful appeal. The odds are still against you though.
The second exception is where there was a mistake on the initial application that can easily be corrected. For example, if your employer entered the wrong start date of employment, and that triggered a coverage denial, an appeal may be effective.
Other than these two scenarios, however, appeals are rarely successful. To make matters worse, the delays associated with appealing will probably worsen your financial situation, and the stress could even aggravate your underlying medical condition.
Whether To Consult A Long Term Disability Lawyer
If you do wish to appeal, you absolutely should consult a long term disability lawyer first. Some LTD lawyers may offer to assist with the appeal for a flat fee or charge an hourly rate. Michael Jordan does not charge fees for helping with appeals. There really isn’t any reason to appeal on your own without first getting some free legal advice.
Sample Long Term Disability Appeal Letter
How To Write A Long Term Disability Appeal Letter: Top 10 Tips
If you do decide to appeal without first consulting a long term disability lawyer, consider the following tips:
1. Obtain your complete file from the insurer: Without your LTD claims file, you are at an information disadvantage. You need to obtain the file to get a better sense why your claim was denied, beyond the brief explanation in the denial letter. A simple email to the insurance adjuster who denied your claim is usually sufficient, such as: “I wish to appeal the denial of my long term Disability claim. Please provide a complete copy of my file.”
2. Review your entire file: Carefully review the entire LTD file to gain insight into the real reason your claim was denied. The denial letter may provide a general statement that you do not meet the test of disability, or that there is insufficient “objective” medical evidence to support total disability. In most cases it is improper for the insurer to require objective evidence. The claims file will contain much more information. After reviewing it, you may discover the insurer was concerned about something you hadn’t considered. For example, a lack of documentation supporting your restrictions and limitations. Or perhaps the insurance company conducted surveillance, which shows you engaged in some activities that suggest you are not disabled. In either case, you now have a focus for your appeal letter. Keep in mind there are also likely legal errors contained in the file, which may be difficult to discover without the assistance of a long term disability lawyer.
3. Obtain new documents: Request a report and updated medical records from all your treatment providers, including your primary care physician, specialist(s), psychologist, physiotherapist, chiropractor, etcetera. These reports should focus on your restrictions and limitations, not just your treatment and diagnosis. The new information to be provided to the insurance company is usually in the form of medical records and reports, but it could also include records from your employer, tax returns, or business documents if you are self employed. Attach these new documents to your appeal letter. Refer to specific excerpts from these records and reports that are particularly helpful to the appeal.
4. Clarify: When writing your appeal letter, explain what may have been overlooked or misinterpreted. For example, if you work at a desk, the LTD insurer may assume that your job duties are light. This may not be the case. Use the appeal letter as an opportunity to explain. If chronic pain or fibromyalgia prevents you from sitting for more than 30 minutes, and your job requires eight hours of sitting with few opportunities for breaks, say so. If you have neck pain that radiates down your arm, and it makes use of a keyboard and mouse difficult, include those specific limitations in your appeal letter. The more focused information you can provide, the better.
5. Respond: Address the specific reason for denial. For example, if the insurer accepts your diagnosis, but doesn’t agree it is disabling, explain your limitations. Use specific examples of tasks you cannot perform at work, and why those tasks cannot be accommodated by your employer. Focus on function over symptoms. If the insurer denied your claim in whole or in part for “workplace issues”, it may have the wrong perception that you are off work because you do not like your job, when the reality is you are unable to handle your occupational demands due to an underlying disability.
6. Provide details: The more information the better, within reason. Keep the appeal letter between one and three pages if possible. You want to provide more information, but only relevant information.
7. Be truthful: Most denied claims include statements from the insured or plan member (that’s you) which make it clear returning to work is not possible. It is likely that the insurer doesn’t fully believe your statements. Claims handlers are paid to be suspicious, and are always on the lookout for even minor exaggerations and inconsistencies. Long term disability insurers will become even more skeptical if you provide any exaggerated or misleading information. This will work against you in the long run.
8. Carefully drafted: The letter should be well written and persuasive. Use clear and concise language. Do not argue. If you are not a strong writer, try to keep your sentences short and to the point. Refer to documents (see point 3 above) whenever possible.
9. Personalize: If you have struggled financially since the denial, say so. If you require benefits to support your family, now is the time to explain your personal situation. Even if the appeal is denied, this could help support your claim later if a lawsuit is required. But again, be truthful without exaggerating.
10. Format: There is no required format you should follow, and each appeal letter will be unique. The content is far more important than the format, but consider adopting the following outline:
- Start with a business letter format, including the date, your address, the insurer’s address, a “re line” containing the claim number and/or policy number, and your signature.
- Begin with an opening line such as “Please consider this letter and attachments an appeal of your company’s decision to deny my claim for disability benefits dated XX”
- Next should be a heading titled “Enclosures” or “Attachments”. Below this heading separately list each document you are including with the letter.
- Include a heading for each point you wish to address. Include one to three paragraphs for each heading. These headings may include, for example: Occupational Duties, Diagnosis and Treatment, Functional Limitations, Surveillance, Personal Impact.
- Place quotations or use separately indented paragraphs when quoting specific documents to make it clear you are referring to something exactly as it is written in the original document.
- Conclude your letter with a brief line such as: “Thank you for your consideration. I look forward to hearing from you regarding the outcome of my long term disability appeal.”
If you follow these suggestions, and provide supporting documentation, there should be a compelling case that you are entitled to long term disability benefits. If the appeal is not successful, and remember most are not, don’t bother with a second or third appeal. It should now be clear that the insurer has no intention of paying your claim, unless it is forced to do so by way of litigation. Further appeals will only put you that much further behind, both financially and emotionally.
If you take one thing away from this post, it should be this: an appeal is probably not your best option. Even the most carefully worded appeal letter is unlikely to change the insurer’s decision.
The second most important take away should be to contact a Long Term Disability lawyer before appealing. There are no fees and no obligation.
About The Author
Michael Jordan is a long term disability lawyer with more than 17 years experience litigating all types of insurance claims. He is a founding partner of the Bay Street firm Jordan Honickman Barristers. Michael represents clients across all of Ontario, with satellite offices in Ottawa and London.
Direct Cell: 416-460-6823