Long-term disability benefits usually start after a waiting period of several months and can last for years, depending on the policy and the condition of the claimant. However, not all long-term disability claims are approved by the insurance company. Sometimes, a claim may be denied for several reasons.
Why was my claim denied?
First, the insurance company may claim that you do not meet the definition of disability under your policy. Perhaps, your condition was excluded or is a preexisting condition that is not covered by the policy. Another reason often claimed is that you do not have sufficient medical evidence or documentation to support the claim.
An insurance company may claim that you did not follow the treatment plan prescribed by the doctor or did not cooperate with the insurance company’s requests for information or examinations. However, they could also claim that you missed a deadline or made a mistake in filing the claim.
The right to appeal
If your long-term disability claim is denied, you have the right to appeal the decision and challenge the insurance company’s reasons. Depending on whether your policy is provided by your employer or purchased individually, you may have different appeal rights and procedures.
Employer policies
If your policy is provided by your employer, it is likely governed by a federal law called the Employee Retirement Income Security Act. ERISA requires you to exhaust all administrative appeals with the insurance company before you can file a lawsuit in federal court. You usually have 180 days to file an administrative appeal after receiving the denial letter. If your administrative appeal is denied, you can file a lawsuit in federal court, but you will be limited to the evidence in your claim file and the court will defer to the insurance company’s decision unless it was arbitrary and capricious.
Private policy
If your policy is purchased individually, it is governed by Texas law and contract law. You may not have to exhaust all administrative appeals before filing a lawsuit, but it may still be beneficial to do so. You should check your policy for any specific appeal procedures and deadlines. You should also submit any additional evidence or arguments that support your claim and address the insurance company’s reasons for denial. You should request a copy of your claim file from the insurance company and review it carefully. If your appeal is denied, you can file a lawsuit in state court, where you may have more options to introduce new evidence and challenge the insurance company’s decision.
