disability benefits denied; how do I appeal or proceed?
September 6, 2023 4:56 AM Subscribe
My long-term disability claim was just denied by my (employer-based, USA) insurance company and I need help appealing this decision. What kind of help do I need?
After the onset of my condition (long covid), I used up all my vacation and sick time, all my employers' patience, and all my short-term disability benefits. Every doctor I've seen has said, yep, you can't work and you're doing all the right treatments, it may just be a couple years before you heal up and can work again. My job provides a long-term disability benefit, which was going to be a lifeline for me during this period. The insurance company says I don't meet their definition of disabled, based on their own internal analysis. I am planning to appeal this and need help but I'm not sure what kind.
In preparing my long-term disability claim, I was very thorough and made sure I answered every question and submitted all the information the insurance company asked for. This would be my plan for the appeal too but I'm worried it won't work. Advocating for myself, and convincing admins that I'm sick/unable to work, is now a necessary fulltime job that I don't have the energy or spoons to manage, for the same reasons I had to stop working in the first place.
(Of course, when I google "LTD benefits denied" or similar, there's an entire industry telling me that an initial denial of benefits is totally ordinary and that I just need to get a lawyer. Even if that's true, I'm resentful about having to step onto this conveyor belt, doing my unwilling part to keep lots of legal/admin folks employed at the insurance company and elsewhere because this is some new normal.)
What kind of help do I need? An employment lawyer? Some kind of administrative expediter or navigator? I've been through my company's employee assistance program (useless in this case; they don't touch employment-related matters for conflict-of-interest reasons) and I'm tapping my personal/local networks for lawyer recommendations. If I end up needing a lawyer, as I suspect, what's a ballpark cost or payment structure? What else am I missing? And do you have any specific recommendations yourself? Thanks.
After the onset of my condition (long covid), I used up all my vacation and sick time, all my employers' patience, and all my short-term disability benefits. Every doctor I've seen has said, yep, you can't work and you're doing all the right treatments, it may just be a couple years before you heal up and can work again. My job provides a long-term disability benefit, which was going to be a lifeline for me during this period. The insurance company says I don't meet their definition of disabled, based on their own internal analysis. I am planning to appeal this and need help but I'm not sure what kind.
In preparing my long-term disability claim, I was very thorough and made sure I answered every question and submitted all the information the insurance company asked for. This would be my plan for the appeal too but I'm worried it won't work. Advocating for myself, and convincing admins that I'm sick/unable to work, is now a necessary fulltime job that I don't have the energy or spoons to manage, for the same reasons I had to stop working in the first place.
(Of course, when I google "LTD benefits denied" or similar, there's an entire industry telling me that an initial denial of benefits is totally ordinary and that I just need to get a lawyer. Even if that's true, I'm resentful about having to step onto this conveyor belt, doing my unwilling part to keep lots of legal/admin folks employed at the insurance company and elsewhere because this is some new normal.)
What kind of help do I need? An employment lawyer? Some kind of administrative expediter or navigator? I've been through my company's employee assistance program (useless in this case; they don't touch employment-related matters for conflict-of-interest reasons) and I'm tapping my personal/local networks for lawyer recommendations. If I end up needing a lawyer, as I suspect, what's a ballpark cost or payment structure? What else am I missing? And do you have any specific recommendations yourself? Thanks.
You might also consider applying to Social Security Disability. I think it's a very good idea to do so (I can expand on this bit, if desired). Neither safety net is great, but SSD is actually a somewhat less labyrinthine and slightly more transparent process than navigating any sort of private insurance, including LTD.
That, too, is a long process, and to optimize your chances of success, you will be best served by getting a lawyer. However, most of them work on contingency, meaning they only get paid (a cut) if your application is successful.
In addition to the ton of info about this out there, this site might be useful: https://howtogeton.wordpress.com/.
Best wishes to you. It's a crazy system that puts so much burden on those already struggling with such challenges.
posted by interbeing at 5:49 AM on September 6, 2023 [8 favorites]
That, too, is a long process, and to optimize your chances of success, you will be best served by getting a lawyer. However, most of them work on contingency, meaning they only get paid (a cut) if your application is successful.
In addition to the ton of info about this out there, this site might be useful: https://howtogeton.wordpress.com/.
Best wishes to you. It's a crazy system that puts so much burden on those already struggling with such challenges.
posted by interbeing at 5:49 AM on September 6, 2023 [8 favorites]
You likely need a lawyer, sorry to say. What that lawyer will do is review your entire medical record, get your doctor(s) to write persuasive letters on your behalf, and package that whole thing into an appeal to the insurance company. This is a specialized type of practice that many lawyers have lots of experience with.
posted by hepta at 6:18 AM on September 6, 2023 [11 favorites]
posted by hepta at 6:18 AM on September 6, 2023 [11 favorites]
When my mom went through this with her late husband (who had fucking metastatic esophageal cancer and was actively dying) they got nowhere on the employer’s long term disability claim until they hired a lawyer.
posted by rockindata at 6:20 AM on September 6, 2023 [3 favorites]
posted by rockindata at 6:20 AM on September 6, 2023 [3 favorites]
A relative also had to get an attorney after her first Social Security disability application was denied. I hope someone else has better news but insurance companies are the worst. Good luck!
posted by Bella Donna at 7:06 AM on September 6, 2023
posted by Bella Donna at 7:06 AM on September 6, 2023
Denial is the standard de facto response to most disability claims. You almost always need a lawyer
posted by couchdive at 2:11 PM on September 6, 2023
posted by couchdive at 2:11 PM on September 6, 2023
If you end up needing an attorney and are based in NC, I do know of an honest (yes, really) guy. Memail me if so, and I'll give you the contact info.
posted by mightshould at 2:32 PM on September 6, 2023
posted by mightshould at 2:32 PM on September 6, 2023
IANYL but you need a lawyer. Many disability lawyers will work on a contingent fee basis of 25-30% of recovery - meaning you don't have to pay anything unless they get a recovery from the insurance company. If you do something wrong procedurally during the appeal, you may lose your right to file a lawsuit following the denial of the appeal, so you certainly want a lawyer to help with the appeal. Often the evidence in the subsequent lawsuit will be limited to the evidence that was submitted during the appeal, so you want to make sure the best evidence is submitted. Many disability insurance companies are borderline scams - they deny all the claims and you won't get any of the benefits you paid premiums for without hiring a lawyer. It's terrible but there it is.
posted by Mallenroh at 4:44 PM on September 6, 2023
posted by Mallenroh at 4:44 PM on September 6, 2023
I am not your lawyer, but I practice adjacent to this area of law and would strongly suggest that you get a lawyer
posted by Red Desk at 10:41 PM on September 6, 2023
posted by Red Desk at 10:41 PM on September 6, 2023
This thread is closed to new comments.
posted by openhearted at 5:29 AM on September 6, 2023 [4 favorites]