If you are just beginning the long-term disability (LTD) appeals process, the world of insurance law probably seems pretty daunting. Every single case is different and has its own complexities. There are phrases and terms that the average person is not familiar with, making it difficult to understand what exactly is going on in your case. LTD cases may seem inaccessible to those not well-versed in the law, but these cases can also serve as important examples to people filing an LTD appeal.
Having Your Benefits Cut Off May Not Be Enough To Trigger LTD Appeal Rights…
In the recent case before the Ninth Circuit Court of Appeals, White v. Anthem Life Insurance, the claimant lost her right to LTD benefits, because she purportedly did not file a timely appeal. How the Court defined what constitutes an “appeal” and “denial” are of particular concern for future claimants with LTD claims.
Under insurance plans governed by the Employee Retirement Income Security Act of 1974 (ERISA), you must exhaust the administrative appeals process set up by the insurance company before you can file a lawsuit. This means that if your claim is denied, you must first appeal this claim denial to your insurance company before you can take them to court. If your administrative appeal is denied by your insurance company, only then can you file a lawsuit against them.
In White, the claimant sent a letter, but the Court found that the claim was not yet denied as defined by ERISA at the time she sent the letter – even though Anthem had already stopped paying her benefits! In short, she needed to submit another appeal following Anthem’s “official” denial letter; the fact her benefits were not being paid was insufficient to trigger appeal rights, because Anthem had not yet determined her entitlement to benefits. Because she did not exhaust the administrative appeals process by appealing the Anthem determination, the Court ultimately sided with Anthem, denying White’s benefits.
Why does this case matter?
The cessation of your benefits may not be enough to trigger appeal rights. Thanks to the White decision, you may need to wait for an eligibility determination before you can timely appeal. It also means that scrutinizing the type of correspondence you receive – and enforcing your rights to timely correspondence – is more important than ever before. However, each case is different with unique facts, so consulting with an attorney is important.
How can I avoid making mistakes in the LTD appeal process?
Make sure you participate in the LTD administrative appeals process in a timely manner before filing a lawsuit. While the Court’s decision in White is unfortunate, it provides a sound reminder as to the importance of engaging in the administrative appeals process. If you’ve submitted an LTD appeal, make sure your appeal is timely and responsive to an adverse benefit determination.
It can be incredibly difficult to understand the LTD appeals process. There are numerous dates, forms, and criteria that must be met in order to successfully file a complete appeal. Going through this confusing process alone can lead you to missteps – which is what your insurance company wants. They want you to be confused and make mistakes so that they don’t have to pay out your benefits. The best way to avoid risky mistakes is to consult with an LTD attorney who can help you make sense of the LTD claim and appeals process.
Why Sandstone Law Group?
The team at Sandstone Law Group has a cumulative 20+ years of experience in LTD litigation. Whether you are just beginning your claim process, filing an administrative appeal, or ready to file a lawsuit against your insurance company, we can help. We take care of your claim so that you can focus on what matters most – your health. And, if your benefits have stopped and you’re waiting for a determination, we can do our best to expedite receipt of that determination or ensure you even need to wait before bringing a lawsuit. Again, every case is unique. Contact us here for a free consultation.