“Frequently, you’ll see there’s a carrier out there that gives you a multiple choice question, but it leaves out ‘none of the above’ as a possible answer,” Whitehead says. “So it will ask, ‘Are you capable of heavy, medium, light, or sedentary work?’ but the client might not be capable of any work. It creates a misleading answer because they can’t choose ‘none of the above,’ so they choose ‘sedentary,’ because it’s closest to the truth.”
Of course, if paperwork is not filled out correctly or if the insurance company believes policyholders have misrepresented their condition in their application, the application can be denied. When the insurance claim is denied, policyholders often then get a letter that is also confusing, leaving them wondering why their application or appeal was not approved. It’s usually at this point that policyholders contact an attorney.
“They shouldn’t do an appeal on their own. They need someone who knows ERISA.”
Insurance companies may deny claims for bad faith reasons or they may deny claims based on a misunderstanding of the policyholder’s disability or job duties. While in some cases, claims have allegedly been denied to protect profits, many claims are denied simply because the insurance company has not put adequate effort into understanding the policyholder’s situation.
Under ERISA law, if the insurance policy is purchased through an employer benefits plan, the policyholder must exhaust all possible avenues of appeal before filing a lawsuit. Even though a lawsuit isn’t initially filed, however, doesn’t mean the policyholder should hold off calling an attorney. In fact, this is an important time to contact a lawyer because any evidence or documentation filed in support of an administrative appeal will also be the only evidence a federal judge sees if the company does not reverse its decision and the case goes before a judge.
“An insurance company is usually happy to let an insured think the appeal is a one-page letter saying ‘please reconsider,’” Whitehead says. “The reality is you may need to talk to vocational and medical experts for supporting evidence. You probably have to do background checks on the insurance company’s own experts to discredit their opinions. A lot of work goes into these appeals. Most administrative appeals are around 100 pages long, not counting medical records.”
Whitehead says the administrative appeal of the denial is a trial on paper, and it’s the only chance policyholders have to get evidence into their file. His firm usually takes around four months to prepare for an appeal, and they hire their own experts for supporting information. Because of the volume of preparation required, the sooner policyholders contact an attorney, the better.
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“[Policyholders] need assistance in handling their appeal by someone who understands federal ERISA law,” Whitehead says.
For policyholders currently applying for disability benefits on their own, Whitehead’s advice is to add as many pages as necessary to the application to give a full and complete picture of their disability. Just because only a few lines are given to describe a disability, doesn’t mean the policyholder should be limited by the space available.
Marc Whitehead & Associates represents disability clients across the United States.