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What Do We Submit for an Appeal of a Disability Insurance Denial?

By: David S. Rintoul

What ZNC’s Connecticut LTD attorneys submit for each appeal is of course different for each client, but here are the general outlines of what we commonly submit:

  • We will always prepare a letter, from six to twelve single‐spaced pages, explaining why our client is entitled to disability benefits.  The letter commonly discusses the following:
    • The client’s medical condition and the disabilities resulting from it, and the medical records in the claim file and records that we obtain and submit with the appeal to support the client’s inability to perform his or her job;
    • The provisions of the plan that are relevant, such as an “own occupation” standard, or the “any occupation” standard”;
    • Why the client satisfies the plan’s definition of disability; and
    • Why the insurer’s conclusion is wrong, responding to  each of the grounds for the denial stated in the denial letter.  This section varies a lot depending on the letter, but for example, if the insurer claims video surveillance shows that the client can do the job, we discuss how the activities in the video are consistent with the disability.  Or, if the insurer claims there are jobs the client can perform, we show that either they can’t perform the jobs, or the jobs don’t pay the income required under the plan.
  •  We will get statements for the treating physicians refuting the specific grounds on which the insurer denied benefits.  For example, if the insurer claims the physical damage to the spine is not serious enough to cause the pain reported by the client, we will have the client’s neurosurgeon give his opinion that the physical damage is consistent with the pain.
  • We may have our client do additional medical testing, such as Electromyography (“EMG” test) to prove that the client has peripheral neuropathy or a neuropsychological exam to show cognitive deficits.
  • We sometimes submit reports from experts we hire, such as a vocational expert to dispute the insurance company’s claim that there is an occupation the client can perform.

ERISA benefit appeals and private disability insurance appeals  can be complex.  As we discuss in our article on the appeal process, your success in court if you sue the plan is directly dependent on what you submit in the appeal. Carefully consider whether a lawyer who is experienced with Connecticut LTD appeals would be useful in navigating the process.  For more information about LTD and ERISA, please see David’s Claimant’s ERISA Blog and the ZNC Employee Benefits practice page.