It can be heart breaking when your long-term disability (LTD) benefits get denied. This is especially true if you depend on those benefits to pay your medical bills and other expenses. However, the fact that you got a denial isn’t the end. If your long-term disability claim gets denied in New York, there are things you can do to fight back. In this guide, we’ll break down the things you need to do next after your claim has been denied.
Your Legal Rights Under ERISA and New York Law
A lot of employer-provided long-term disability plans are controlled by the Employee Retirement Income Security Act (ERISA). This is a federal law that sets strict rules for claims procedures. While ERISA allows you to appeal, it also limits your options later. This means courts reviewing ERISA cases can’t accept new evidence after the administrative appeal has been filed.
If your policy is not under ERISA, then New York contract law comes into play. This is the case for people who got their disability coverage directly from an insurer like New York Life. In this case, you can file your lawsuit without having to pass through the full administrative appeal process. It also allows you to claim “bad faith” damages if the insurer didn’t act fairly.
What to Do After Your Long-Term Disability Claim Gets Denied
Follow the steps below if your claim was denied.
1. Read the Denial Letter Carefully
The first thing you need to take is to carefully read the denial letter. By law, insurance companies must explain why they deny a claim. They also have to outline your right to appeal. The denial letter must include:
- The specific reasons for denial. It could be due to lack of medical evidence, missed deadlines, policy exclusions, etc.
- The appeal deadline. For ERISA-governed plans the limit is 180 days.
- Instructions for how to appeal.
Ensure that you mark the appeal deadline immediately. If you miss it, you can say goodbye to any chance of changing the outcome.
2. Review Your Disability Policy
The next step involves reviewing your disability policy. You need to know the terms that apply to you. Pay attention to the following:
- Definition of disability: Some policies only apply if you cannot carry out your recent job.
- Exclusions and limitations: Mental health claims, for instance, are limited to just 24 months under certain policies.
- Procedural requirements: It is your policy that will guide you on how to submit an appeal. It will also tell you the evidence you need to include.
When you fully comprehend the terms of your policy, you can boldly tackle your insurer’s arguments and strengthen your appeal.
3. Gather Strong Supporting Evidence
One reasons a lot of disability claims are denied is because they lack sufficient medical evidence. To make your case stronger, gather the following:
- Updated medical records
- Detailed letters from your doctors explaining your restrictions
- Independent medical evaluations (if possible)
- Vocational or occupational expert reports that describe how your disability prevents you from working
- Personal statements from yourself, family, or coworkers.
Organize and store all this documentation. Bear in mind that you cannot add new evidence after you’ve filed the appeal, especially under ERISA law.
4. File a Timely Written Appeal
Now that you have your evidence, go ahead and submit your formal appeal. In your letter, you must explain why you disagree with the claim denial. You should also summarize the new documentation that supports your claim. Make sure you:
- Include every piece of supporting evidence
- Submit before the appeal deadline
- Confirm that your appeal was received by the insurer
Under ERISA, insurance companies have 45 days to respond to an appeal. While there is the chance to request another 45-day extension. During this period, continue to check from time to time to confirm your appeal is being reviewed.
Seeking Legal Help
Appealing is not something most people can handle on their own. It is a complex legal process, and a small error or missed deadline could jeopardize your benefits. This is why many people turn to experienced lawyers in New York who specialize in long-term disability cases. Because they understand ERISA requirements, and how insurers handle claims, they can ensure your appeal is complete and persuasive.
In case your appeal fails, they will help you file a lawsuit against the insurer. Under ERISA, the litigation is handled by a federal court, and the judge will only review the claim file evidence. In cases not under ERISA, you have the chance to add new evidence and seek additional damages. The catch is that these lawsuits are usually lengthy and complex. So, having legal help will be of great benefit.
Endnote
If your long-term disability claim has been denied, you don’t have to lose your marbles. There are steps you can follow to appeal the denial and get your rightful benefits. In the article above, we’ve shared these steps to guide you during this trying period.
