Many of our clients think that the appeal package is simply a compilation of medical records sent to the insurance company with a cover letter identifying the package as an appeal. While that may be the case for claimants who file their own appeal, the appeal packages prepared by Ortiz Law Firm are much more detailed.
Appeal Preparation Timeline
Most long term disability insurance policies require that the appeal be filed within 180 days of the date of the denial or termination letter. Even after we obtain all of the medical evidence there are several other steps we must complete before we are ready to submit the appeal package:
Review of The File
First we review the claim file for accuracy and flag any damaging information we will need to dispute in our appeal letter, such as video surveillance, Independent Medical Examination reports, peer physician reviews and vocational reviews.
Review of The Evidence
We also review all of the medical evidence that we have received for accuracy, and then we prepare a detailed medical summary to incorporate into the appeal letter. We focus on notes from the medical records that will support the claim such as limited range of motion, spasms, reduced grip strength, etc., and we reference any MRIs, X-rays, ECGs, EKGs, Neuropsychological evaluations, and any other tests or evaluations that support your claim for benefits. We also use discretion as to whether certain records should be submitted, such as records where a doctor noted work activity (where there was none).
Finally, we begin the legal research process. Each appeal letter includes a detailed legal analysis in which the attorney will compare your claim to other disability claims that were decided in a United States District Court, U.S. Court of Appeals, or even the U.S. Supreme Court, and cite case law which demonstrates that the insurance company was wrong to deny your claim for benefits.
Things that Slow Things Down Once Appeal is Filed:
Once we file an appeal our clients always ask the same question: How long until I receive a decision? Pursuant to Federal Law, the insurance company must issue a decision on an appeal within 45 days from the time they receive the appeal. We typically allow them an additional 5 days for mail time, making this 50 days instead of 45 days. Also pursuant to the law, they may receive an automatic extension of 45 days to issue a decision. See 29 C.F.R. §2560.503-1(i)(3)(i). The insurance company does not need our permission to invoke this extension. It is automatic upon their request. Despite these statutory deadlines, there are other situations that can slow things down and extend the insurance company’s deadline to issue a decision.
Additional time may be needed if the insurance company determines that they need additional information. The insurance company will “toll” the running of the time to issue a decision. Tolling means that the number of days that the toll is in effect is not counted towards the number of “decision days” the insurance company is allowed to issue a decision. Once tolling stops and the counting of days to the insurance company’s decision deadline resumes, they will proceed with making a decision within a reasonable period of time not to exceed the number of decision-making days that are left after tolling ended.
You may be wondering what additional information the insurance company would need if we have already obtained all of your medical records. If your records indicate that you will be receiving additional treatment in the near future then the insurance company may wish to wait and obtain that new evidence.
The insurance company may also order an “Independent” Medical Examination (IME). If so they will have to identify a doctor with the appropriate specialization that practices in your area and schedule an appointment for you with said doctor. Depending on the doctors availability the IME may not take place for several weeks. If you happen to be unavailable on the proposed date for the IME then the insurance company will have to contact the IME doctor again for updated available dates.
Once you attend the Independent Medical Examination we will have to wait for the IME doctor to prepare his or her report and forward it to the insurance company. Then we also have to wait to receive a copy of the report from the insurance company. We will review the report, and if it is unfavorable we will ask you and your doctors to assist in disputing the report. While we may receive your response very quickly, it usually takes about 30 days to receive a response from a doctor (if we receive a response at all).
It is also possible that the insurance company will request a peer review or vocational review of your claim file. Unlike an IME, these are paper file reviews and the reviewer will only have access to the documentation in your claim file, so you will not have to wait for an appointment. However, it does take time for the reviewer to review your file, write his or her report, and submit the report to insurance company. We also have to wait to receive a copy of the report. We will then review the report, and if it is unfavorable we will ask you and your doctors to assist in dispute the report. Again, it usually takes about 30 days to receive a response from a doctor, if we receive a response at all.
The insurance company may also try to engage in “peer-to-peer” communication between the reviewing physicians and the claimant’s doctors, which is usually a letter to your doctor(s) asking if they agree with the reviewer’s assessment. The insurance company will give a specified time frame to receive a response, and the claim will not move forward until the response is received or the specified timeframe for a response has run out.
While many of our clients hope to receive a decision regarding their appeal as soon as possible, it is important that we take the time to dispute damaging information that is produced by the insurance company during the appeal review process. Should your claim proceed to litigation the judge will only review the information that is in the claim file and we will not be allowed to introduce any new evidence.
Legal Representation in Long Term Disability Insurance Claims
Although based in Florida, the Ortiz Law Firm represents claimants across the United States. If your LTD claim has been wrongfully denied, delayed or terminated and you’d like to speak to an experienced Long-Term Disability Insurance Attorney contact us at (888) 321-8131 to schedule a consultation. We can help you evaluate your claim to determine if you will be able to access Long-Term Disability Benefits and how to move forward with the process.