Although you do not necessarily need an LTD attorney for your administrative appeal, having one substantially increases you chances of winning. An LTD attorney at Operana Law will do more than just write an appeal letter for you. We will get all of your files and documents from the insurance company and conduct an in-depth review to see why they denied you. Then we will reach out to your treating doctors and have them provide us with opinions to support your case. We then draft a formal appeal, similar to one that we would draft if your file was being reviewed by a judge in a court. After your appeal is submitted to the insurance company, we continually follow up and make sure we are involved in the appeal review process. This includes working with the insurance company, their doctors, and your doctors. We will do everything we can to help you get benefits.
Why is the Appeal Guarantee important?
You have spent enough time during the insurance company denial process. You do not have time to sit and wait while your attorney works on your case. Sometimes attorneys are too busy and you may not be their number one priority. At Operana Law, we understand time is of the essence in your case. Therefore, we offer the Appeal Guarantee. We guarantee that within 48 hours of having all of the necessary documentation for your appeal, we will file your formal administrative appeal with the insurance company.
Ask any other law firm out there if they have any sort of Appeal Guarantee and their answer will most likely be no. Ask any other attorney out there when they will file your appeal and they will likely not give you a definitive answer. At Operana Law, we guarantee that your appeal will be filed within 48 hours after receiving the information we need. Its that simple.
What should I do after I receive my long-term disability denial letter?
When you first get your denial letter, you will want to read over it carefully. Look at why the insurance company is denying you. Did they receive all of the necessary information? Are they denying due to a pre-existing condition? Are they denying you and claiming that you are no longer disabled? Or is the insurance company saying you are not disabled from any occupation?
Whatever the case may be, you next step should be to contact an LTD attorney. Pretty much any LTD attorney is willing to offer you a free consultation. At Operana Law, we will offer you a free consultation as well as a free Appeal Evaluation. During this evaluation, we explain the appeal process, your chances, why the insurance company denied you, and what will be needed in order for your to win. This is free to you even if you do not sign up. There is no obligation for the phone call or advice.
How does Social Security Disability affect my LTD benefits?
Your insurance company usually requires you to apply for Social Security Disability (SSD) benefits. This is because in most LTD policies, there is an offset that occurs when you receive SSD benefits. Usually, your LTD benefit amount is reduced by the amount of your SSD benefit amount. Your LTD benefit amount may also be reduced by other Social Security Benefits you and your family receive, such as dependent and spouse benefits. You may also be required to pay back all or a portion of your retroactive SSD benefits (back pay/past-due benefits).
What are some of the offsets that may impact my claim?
Your insurance policy typically lists what sorts of offsets apply to your case. The most common offsets are those related to your disability, such as Social Security, state-disability payments, VA benefits, disability benefits from any other disability insurance policies you may have, and any retirement/pension accounts you may have or be entitled to. It is important to remember however, that the insurance company sometimes miscalculates your benefits and offsets things that should not otherwise be offset. If you feel that your benefit amount is significantly incorrect, please contact us to discuss your rights.
What do I do if the insurance company wants me to attend an IME?
You should prepare for the worst after you receive a notice to attend an Independent Medical Examination (IME). More often than not, the insurance company is sending you to an IME so they can terminate your claim and stop paying you benefits. Insurance companies usually hire a doctor that they have previously used, in some instances, hundreds of times in the past. This doctor typically conducts a very brief examination and provides his or her report back to the insurance company. Based on that report, the insurance company will decide whether you still meet their definition of disability or not. Many individuals are denied benefits following an IME. If you have been scheduled for an IME, recently attended an IME, or have been denied following an IME, you should contact an attorney right away to discuss your legal rights and options.
Should I pursue an appeal or file a lawsuit?
Cases governed under ERISA require you to file at least one administrative appeal to the insurance company. Once that appeal, and any subsequent appeals are exhausted, you then have the right to file a lawsuit. We typically recommend that you file an appeal and and that point, decide whether you want to file a lawsuit or pursue a second administrative appeal, if allowed. Sometimes, it is better to work with what is already in the file, rather than giving the insurance company more chances to strengthen their case. On the other hand, if you case has some weak spots or issues, you may want to consider filing a second appeal to address those problems before filing a lawsuit.
What is ERISA and how does it impact my case?
ERISA stands for the Employee Retirement Income Security Act of 1974. It is a federal law that was enacted to set minimum standards for employer sponsored pension and health care plans. The Act was designed to protect individuals’ retirement and income rights. Most Long-Term Disability policies are governed by ERISA law. Typically, group policies provided by employers qualify under ERISA while individual policies are governed under State Laws.
ERISA gives individuals many protections that did not once exist. Because of ERISA, insurance companies must now provide the plan participant with plan information, important facts about the policy, the standards of reviewing your claim, etc. ERISA also sets rules for the insurance administrators’ fiduciary duties. In other words, ERISA requires that the insurance company deciding your claim do so promptly, neutrally, and properly.
My insurance company said I could return to work in another occupation, what do I do now?
Most disability insurance policies are two-fold. The insurance company initially pays you benefits if you are disabled from your "own-occupation." Most policies pay own occupation benefits for a period of 24 months. After that time period, the definition of disability often changes to "any-occupation," meaning the insurance will only continue to pay you if you are disabled from performing the material and substantial duties of any job.
More often than not, insurance companies use this change to deny many individuals. They usually have your claimed reviewed by one of their doctors and a vocational expert and state you are now able to return to a different job. If this is the case, you should contact us right away so we can advise you of your rights. If your doctor has not released you back to work and you still feel disabled and incapable of doing anything, you should continue to receive LTD benefits.
My policy has a mental health limitation, is there a way around that?
Most LTD insurance policies have strict time limitations for mental health condition- usually up to 24 months. However, some policies have additional provisions depending upon the type of mental illness or the type of treatment you are undergoing. For example, some policies allow continued payments of benefits after 24 months if you are diagnosed with bipolar disorder, dementia, schizophrenia, etc. Some LTD policies also allow continued payments if you are institutionalized or hospitalized after 24 months.
If you have questions on whether you may be entitled to ongoing benefits, we would be happy to discuss your options with you. You should also look out for whether your insurance company is classifying your condition as a mental health illness when it is actually a physical condition. If you feel that is the case, contact us right away.
I was denied due to a pre-existing condition, what are my rights?
Almost all LTD insurance policies have pre-existing condition limitations. Typically, if you become disabled and apply for LTD benefits within a few months to a year of your policy becoming effective, the insurance company will check to see if your condition was pre-existing. The insurance company typically looks at the 3-12 months prior and/or after to your policy becoming effective. They look at whether you received any medical treatment or care, or took any prescribed medications for your disabling condition. Sometimes, insurance companies misclassify your conditions and consider something pre-existing when it is not. Other times, insurance companies link a medication you took to your present condition, when in fact, it had no relation whatsoever. Whatever the case may be, we urge you to contact us if you feel that you are being unfairly denied based on a pre-existing condition limitations. We may have a workaround and can help you get benefits.
I also had a Life Insurance policy with my employer, will I still have that policy if I get denied my LTD benefits?
Usually, if you are receiving LTD benefits, your insurance company waives your life insurance premiums. Therefore, as long as you remain disabled, your premiums will be waived and you will still have life insurance. However, if your insurance company decides that you are no longer disabled, they will cease paying your premiums and you will no longer have life insurance. Sometimes, insurance companies give you the option to pay your own premiums in the future or allow you to cash out the value of your policy.
If you get denied your LTD benefits and your life insurance, we can assist you in appealing your LTD benefits claim and if you are reinstated, we will also help you with getting your life insurance benefits back and your waiver of premium paid.
When should I hire a Long-Term Disability attorney?
If you get denied benefits, you have the right to hire an attorney to help you appeal. Often times, your insurance company will tell you that you do not need an attorney and you should submit your appeal right away. However, this is bad advice. If you appeal your claim on your own and get denied again, you may not have another chance at appealing. Most attorneys will not accept your case for lawsuit if they did not have the opportunity to work on it previously.
If you get denied, we recommend contacting an attorney right way, just to discuss your options and rights. You do not necessarily have to retain that attorney, but it is always helpful to know where you stand. Operana Law would be glad to give you a free consultation on your case and we can even advise you on whether you should get an attorney, depending upon the stage your case.
If you have already appealed your case and been denied, but your insurance company is giving one last chance at appealing, we urge you to definitely use an attorney at that point. If you have exhausted all your appeals and need to file lawsuit, we would also recommend hiring an attorney to help you navigate through the lawsuit and court filings process.
My insurance company set me up with an attorney to pursue Social Security Disability benefits. What are my rights and options; must I use their attorney?
Most LTD insurance policies require you to apply for Social Security Disability benefits. To assist with this process, the insurance company will typically refer you to an attorney, law firm or similar company/organization to help you apply. However, you have the right to either apply and pursue your own Social Security claim, use the referral from the insurance company, or hire an attorney of your choosing.
At Operana Law, we not only specialize in assisting you with your LTD claim, but we can also represent you in your Social Security claim. We have done hundreds of hearings before Social Security Administrative Law Judges and have assisted thousands of individuals in obtaining Social Security benefits. Call us today to discuss your rights.
What if I return to work; can I still collect benefits?
Although you have a claim for "long-term disability" benefits, that does not necessarily mean you will be permanently disabled. Many individuals recover or become well enough to return to the work force, either at their previous occupation or in another position/field. If you were off work for a few months or up to a year or two, and applied for LTD benefits but was denied for your claim, we may be able to assist you in recovering benefits for the time you were disabled and off of work, even though you have returned to the work force. Even if no longer work at your old company or if you have been denied your appeal, we may still be able to assist you in pursuing an ERISA lawsuit against your insurance company.
On the other end, what if you are able to return to work part time, either at your old job or at a different one? Even in this situation, we can still possibly assist you in claiming benefits, or at least a portion of what you were owed. Contact us today to discuss your options.
I appealed my own claim and now I must file a lawsuit, can you still help me?
Yes we can. Although, most attorneys prefer to assist you during the administrative appeal process, Operana Law may still be able to assist you in filing a lawsuit. Most attorneys at this stage have to take precautions on accepting your case however, because since they were not involved in the initial appeal, they did not have the opportunity to build up and strengthen your case. That puts many attorneys at a disadvantage. Despite this, you should still contact us to see if we can help.
Can the insurance company legally conduct surveillance on me?
Most insurance companies conduct a form a surveillance on you. Whether it be a private investigator following you or the insurance company investigating your activities online, they have the right to do so to an extent. Essentially, a private investigator can observe you from outside of your home or following since they are in a public place. The insurance company can also observe your activities online, such as social media, Facebook, and message boards, since those are also available to the public. However, if you feel the insurance company is being too intrusive on your personal life, such as trespassing on your property or harassing you, you should call us right away so we can help.
I feel my benefits have been miscalculated and that I am being underpaid. What are my rights?
Most LTD insurance companies verify your salary and wages with your employer prior to paying you benefits. Sometimes, employers give wrong information or do not provide complete information to the insurance company and therefore, your benefits become miscalculated. Other times, the insurance company can miscalculate your benefits on their own, either just underpaying you or not taking into consideration overtime wages or on-call pay. If you feel your benefits are incorrect, you should obtain a copy of your policy and contact us to review all of the information and to determine if everything is correct.
I received a notice of over payment, what are my rights?
First recognize what the over payment is in regards to. If the insurance company has mistakenly paid you twice for the same time frame, then often times, you'd have to reimburse them even though it was their mistake. If the over payment is due to an award for Social Security benefits, or other disability/injury benefits, you may or may not be liable to pay the insurance company back depending upon what your policy states. Sometimes, insurance companies miscalculate an over payment and or claim something has been overpaid when your policy states otherwise. If you have a legitimate over payment and are unable to make payments due to financial hardship, your insurance company may also work with you on an installment plan. We may also be able to help negotiate an over payment for your and settle out your claim completely with your insurance company.
How long do I have to pursue an administrative appeal or file a lawsuit in my claim?
Under ERISA, you typically have 180 days to file your request for an administrative appeal. After you file, you may also have the opportunity to submit additional information that were not able to submit by the deadline. It is important to not wait until the last minute to file your appeal. If you plan on using a lawyer to help you, you must contact the lawyer well in advance so that attorney has an opportunity to review your claim, you files, and work up your case. We typically prefer to have at least 2-3 months to work up your case before the deadline; however, we have accepted cases with less than a month in the past. Your best option is to get the information you need and appeal your case right away, or at least contact an attorney to discuss your appeal rights as soon as you receive the denial.
How long will my case take to resolve?
Typically, after you file your appeal, the insurance company has 45 days to give you a decision. If they cannot reach a decision after 45 days, they can request one extension of another 45 days, but they must give you a reason. Delays for decisions may be due to trouble getting medical information, your physicians not responding, or the insurance company's doctors not providing timely reports. If you do not receive a decision after about 90 days from submitting your appeal, the insurance company has violated your rights. You should contact us right away to discuss your options and whether a lawsuit is necessary.
What is your experience with CIGNA?
We have dealt with CIGNA (Life Insurance Company of North America) quite often. CIGNA is one of the biggest long term disability insurance companies. We have done numerous administrative appeals and lawsuits against CIGNA. CIGNA is also one of the few insurance companies that allows you to have a second administrative appeal if the first is denied. This may or may not be a good idea to pursue depending upon the circumstances on your case.
If CIGNA denies your claim, they usually have a Nurse Case Manager (NCM) or Medical Director (typically a medical doctor) review your claim. CIGNA may also refer your claim to a third-party physician for an “independent review.” However keep in mind, these third parties are still being compensated by CIGNA and often do many reports for CIGNA, so inherently, there is still a conflict of interest between them. Finally, CIGNA may personally send you for an independent medical examination (IME).
To be successful in CIGNA appeals, you often have to provide all of your updated medical information and opinions from your doctors. We also provide legal arguments when filing CIGNA appeals to strengthen your claim. If you have CIGNA and worried that they may deny you, or if they have already denied your claim, call us today.
What is your experience with MetLife?
We have had many cases against MetLife – both with appeals and federal court lawsuits. MetLife, like most other insurance companies, is known to deny claims and allege that you are no longer disabled or are able to return to another occupation. MetLife will typically have your claim reviewed by one of its reviewing decisions or an outside third party physician. MetLife also sometimes has vocational reviews that determine what job you may be able to return to, or whether you have the ability to earn a certain amount in order to still be qualified or not.
We have also experienced MetLife deny a claim once we have gotten it approved. For example, we were successful upon an administrative appeal and then a few months down the line, MetLife again denied the claim. With our lawsuits, we have been successful in resolving many of our client’s disputes against the insurance company.
If you have MetLife and fear they are going to deny you, or if they have already denied you, you should contact our experienced LTD attorneys to discuss your rights and what would be helpful in providing MetLife to overturn your denial.
What is your experience with Principal Life?
Principle Life's headquarters is geographically located near our offices and we have had many cases against them in the past. As like most insurance companies, Principal's objectives are different from yours. Although you are disabled and not able to return to work, Principal may disagree and say that you are well enough to work and therefore, not qualified for benefits.
In our experience with Principal, they typically have an in-house medical professional review your claim and/or send your claim out for an "independent review." However you should be wary, as those independent reviewing physicians are still compensated by the insurer and may not always have your interests in mind.
We have not recognized Principal to send claimant's for independent medical examinations that often, however it is still possible. In our experience, we also recognize many individual who get terminated after their 24 month own occupation period. If this has happened to you, or if you just have general questions about your claim or denial, you should contact us right away.
What is your experience with Sun Life?
Sun Life Financial, a Canadian based company, is notorious for denying claims upon initial application and after your “own occupation” period. In our dealing with Sun Life, we routinely see their doctors miss key medical information and ignore your treating physician’s opinions. We have also seen Sun Life conduct inadequate surveillance of disabled individuals and have non-specialty doctors evaluate medical evidence. We have assisted many people with both appeals and Federal Court lawsuits against Sun Life and have a great success rate in obtaining benefits and/or lump sum settlements.
What is your experience with Liberty Mutual?
We have assisted many clients with both appeals and lawsuits against Liberty Mutual. Like most insurance companies, Liberty Mutual works hard to deny claims when your policy’s definition of disability changes to “any occupation.” Liberty Mutual’s medical and vocational reviews often lack substance and are typically not fully supported by the evidence in the file. We usually have to supplement the record with your own treating physician’s opinion and our own vocational experts in order to overcome Liberty’s denial of benefits.
Also, most recently, as of 2018, Liberty Mutual was acquired by Lincoln Financial Group, another large life insurance and long-term disability insurance carrier. Following the acquisition, we noticed a large influx of claims going under re-review, which has led to a lot of improper denials. If this has happened to you, you should contact us right away.
What is your experience with The Standard?
Based on our statistics, The Standard typically denies many claims upon application and at the end of the own occupation period. The Standard usually argues that the disabled individual failed to provide adequate medical information or that their condition and symptoms do not cause severe enough restrictions. We have experience dealing with both administrative appeals and lawsuits against The Standard. When dealing with The Standard, we highly recommend an attorney during your first appeal and they typically only give you one chance at appealing, unlike other insurance companies.
What is your experience with Reliance Standard?
Reliance Standard has a track record of improperly denying claims. We have worked on many appeals and lawsuits against Reliance Standard. In many of our cases, we actually work very closely with the adjuster and have direct contact via phone and email. We have seen first hand the sorts of bad faith efforts given by claim handlers and adjusters when it comes to your LTD claim. We have been successful in arguing directly to the adjusters and their superiors, sometimes without having to file formal appeals or lawsuits. In our experience, Reliance Standard, just like many other insurance companies, conducts bias medical reviews and ignores a lot of the medical and vocational information provided.
What is your experience with Prudential Insurance?
Prudential is one of the largest life insurance and long-term disability insurance carriers. We have been successful with both administrative appeals and Federal Court lawsuits against Prudential. We have also been successful in obtaining past-due benefits and lump sum awards and have routinely dealt with Prudential’s attorneys.
Prudential, like many other LTD insurers, will typically have one of their doctors review your records and make a decision on your disability, all without actually examining you. More often then not, their doctor’s misstate and ignore your medical information when forming their opinion, which ultimately leads to a denial. We have been successful in overcoming these denials by obtaining support and clarification from your own treating physicians, as well as providing support from vocational experts.
What is your experience with Aetna?
We have seen many claims get denied by Aetna at all stages. Clients who have been on disability for nearly 10 years have been denied out of the blue for no reason. We have also seen Aetna move a person’s date of disability into the future which has resulted in a lack of past benefits. In dealing with Aetna, we routinely see inadequate medical reviews and bad faith by the insurance company when it comes to obtaining your medical records. Aetna’s claim handlers also do a poor job of following up with you and your doctors when reviewing your claim. Don’t be a victim to Aetna’s antics—get our help with your claim today.
What is your experience with UNUM Insurance?
In our experience, Unum has consistently given individuals a difficult time when it comes to obtaining LTD benefits. They usually have their own doctors and medical professionals review your claim and make a decision on your disability without ever examining you. Unum also conducts inadequate vocational reviews and terminates many claims after the “own occupation” period. It is very important that your doctors are on board with your disability claim and also communicate to the insurance company. We have dealt with Unum on many occasions, both with lawsuits and appeals, so contact us today for a free consultation.
What is your experience with The Hartford?
The Hartford consistently works to deny LTD benefits for its claimants. Whether they have just applied, are at the “any occupation” stage, or have been on claim for years, you are never safe when it comes to the Hartford. Like most other insurers, the Hartford conducts bias and insufficient medical reviews and fails to obtain all of your medical information. In cases where we have been successful with the Hartford, we have had to obtain complete copies of medical records and updated opinions in order to correct all the inaccuracies by the insurance company. We have also demanded actual medical exams in instances where the Hartford denied the claim but did not have the person examined. Do not fall victim to the Hartford’s trap in appealing your own claim, legal assistance is strongly recommended when dealing with this insurer.