Responding To New Information During Your Short- or Long-Term Disability Appeal
You appealed a denial of your Short- or Long-Term Disability claim. Now the insurance company is asking you to respond to a report from a doctor that they hired to review you records. You might be confused as to what is happening. Why does the insurance company want you to respond to this report? What kind of information should you provide?
The Appeal Process
If your Short- or Long-Term Disability Insurance company denied your claim, you may have filed an appeal on your own. If your insurance policy was provided through your employer and you are not employed by a government employer or church, your policy is likely governed by the Employee Retirement Income and Security Act of 1974 (or ERISA for short.) ERISA provides a multitude of procedural regulations that the insurance company has to comply with during the handling of your claim, including during the review of your appeal.
Reviewing and Responding to New Evidence Generated on Appeal
During the appeal process, the insurance company will generally provide all of your medical records and any updated information that you submitted with your appeal to a medical provider that they have hired to review your medical records. If that reviewer agrees that the evidence supports that you are disabled according to the terms of your policy, the insurance company should overturn its denial and start paying you benefits. If the reviewer believes that the evidence does not support that you are disabled under the terms of your policy, the insurance company has to provide you with a copy of that report for you to review and respond to.
It is very important to respond to this report.
First, the additional information you provide may convince the insurance company to agree with you and your doctors over the opinion of its hired doctor. However, even if the insurance company will not change its mind, it is still important to provide all possible supportive evidence to the insurance company during the appeal stage. The reason for this is that once you have exhausted the administrative appeals process the next step is a lawsuit against the insurance company and you are generally
not able to submit additional information to the court beyond what is contained in the administrative record. (For information on the hurdles faced by claimants during the litigation phase of these cases, see “
An Uphill Battle: Understanding the ‘Arbitrary and Capricious’ Standard of Review.”)
Seek Legal Counsel Before Responding to a Report from an Insurance Company's Doctor
Due to these factors, responding thoroughly to a report from the insurance company's doctor during the appeal stage is of utmost importance. Even if you did not retain an attorney to file the appeal initially, you should consult with an attorney if the insurance company provides an unfavorable report from its medical reviewer during this appeal review stage. An attorney can help determine what would be the best evidence to submit to the insurance company and can also provide legal arguments to the insurance company about why they should credit your doctors’ opinions over the opinions of a hired doctor who reviewed your records. Even if this does not change the insurance company’s mind, the attorney will have helped your case by including more favorable evidence in the record that the judge can consider when you go to court against the insurance company. If you are in this situation, contact our firm today to speak with one of our experienced Long-Term Disability attorneys