Our office received a call recently from Janice – a very nice, 56-year-old accountant who was dealing with coronary artery disease (CAD), diabetes, and chronic degenerative disc disease. Janice worked as an accountant at a large, chemical manufacturing facility for almost 25 years.
She had to stop working due to her medical conditions and filed a claim for long-term disability benefits through her employer’s benefit plan.
Unfortunately, she was denied because the insurer claimed she could continue doing her sedentary occupation.
She was really angry and did not want to deal with the insurance company any longer because she knew she would not get a fair shake. Janice just wanted to sue them.
After a few minutes, Janice asked – Do I have to submit an administrative appeal of my long-term disability denial?
Do I Have to Submit an Administrative Appeal of My Disability Denial?
The answer is yes if you received your LTD plan through a private-sector employer.
Long-Term Disability coverage provided this way likely falls under ERISA and according to ERISA and federal law, you must “exhaust” your administrative remedies if your disability claim was denied before you can file a lawsuit.
That’s a fancy way of saying that you must follow the process.
This means you must follow the terms of the insurance policy and go through each step of the appeals process directly with the insurance company.
If the insurance policy states that you must file one appeal, then you may only need to file one mandatory appeal.
If the insurance policy requires you to file two appeals, then you must go through two appeals before filing a lawsuit.
Other insurance policies have one mandatory appeal and one “optional” appeal. The key is that you must review your policy to see what it requires.
If you try to skip the administrative review and go directly to court, the court will most likely say that you failed to exhaust your administrative remedies and can dismiss your appeal.
In other situations, you may not have to file an appeal at all before filing a lawsuit. This may be the case if you have an individual policy purchased directly from an insurance agent or broker, or if your policy is sponsored by a government or church employer directly. Again, you should read your policy.
Luckily for Janice, she made a smart choice and called the LJB Legal team so that we could evaluate her situation and guide her correctly (since she received her policy through a large, private-sector employer her claim was guided by ERISA and she had to do the administrative appeal).
Your situation may be different and will be dependent on the specific facts and policy provisions of your policy.
If in doubt, you should contact an experienced disability attorney to help guide you through the process. Give our office a call at 985-240-9773