DOUBLE STANDARD? THE NEED TO FILE A STRONG INTERNAL APPEAL
October 12, 2011 by Danielle Schroder
If you have been denied long term disability insurance benefits, you should not wait until the matter ends up in court to vigorously contest the denial. The law that governs benefit denials, and especially the standard of review used by the court, will place you at an immediate disadvantage.
In cases involving ERISA governed plans, the court likely will review the benefit denial under an Abuse of Discretion Standard. Under this standard the court will review the record to determine whether the insurance company’s decision was reasonable and adequately explained. In other words, while the court may disagree with the insurance company’s decision to deny your benefits, the court may uphold the denial if it believes the insurance company acted reasonably.
This standard is triggered by discretionary language in the policy stating something such as, "benefits under this plan will be paid only if the plan administrator decides in his discretion that the applicant is entitled to them." So long as the policy includes this trigger language granting the administrator discretion to decide whether or not you are entitled to benefits, a court will not decide for itself whether you are in fact disabled.
The ability to secure long term disability insurance benefits depends in large part on a well-developed internal appeal. For example, you will want to include all supporting medical evidence, dispute the opinions used by the disability insurance carrier, provide witness statements, and in general, prove to the insurance carrier that it wrongfully denied your claim for benefits. Retaining experienced legal counsel before exhausting your administrative appeals can help you put together the comprehensive appeal necessary to obtain benefits.
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