Ask the Chronic Fatigue Syndrome & Myalgic Encephalomyelitis Disability Attorney
Your Rights When a Disability Claim is Terminated
By Jason A. Newfield and Justin C. Frankel, Attorneys at Law
The termination letter always comes as a shock. You know that you are too ill to work, and so does your doctor. It's frustrating, frightening and makes you feel powerless. But the important thing to remember about a disability benefits termination is that you have to act in a timely fashion and stay focused to protect yourself and your family.
First - understand that there are often strict time limits on the appeals process, and they have been backed by a United States Supreme Court decision, Heimeshoff v. Hartford. The clock starts ticking from the date that your "proof of loss" is due. This might be before any lawsuit or appeal is filed, could be while you are still receiving benefits, or even before you have exhausted your administrative appeals process, which must happen before you can start a lawsuit to fight for your claim (on group claims).
Information about your right to appeal, your right to access the documents in your claim file and other information about the appeals process was probably included in the letter advising you that your claim was being terminated. Read this letter carefully.
Typically, on an ERISA disability claim, you will have 180 days from the date of claim determination to file your appeal. This is a critical time for your claim. If you are not sure about what to do, speak to an experienced ERISA disability lawyer about the issues. If you miss your deadline, your claim will not be able to be resurrected.
Often, claims are terminated based on medical record reviews that are conducted on a regular basis as part of how the insurance companies manage their risk exposure. The reviews are done by insurance company employees - some are medical professionals, and some are not. Often the reviews are conducted by third -party companies whose sole function is to review medical records and deliver results to the insurance company. Since their clients are the insurance companies, these reviewers have a vested interest in keeping their clients happy. This often means that the reviews are skewed in the insurance company's favor.
We call these reviews "paper reviews" because the insurance company is basing their termination decision on a review of a paper file and not a person. The reviews are often so far off base that even the most skeptical person has to be surprised that benefits have been terminated.
What are your rights after a termination? You have a right to fight back. First, write to the insurance company and ask for a complete copy of your claim file. Anything you send to the insurance company should be sent by express mail service so that you have proof of the date of the correspondence and a signature proving that it was received. Keep a copy of what you sent, and any receipts or mailing labels that show the date that the letter was sent and when it was received.
Contact your doctors. You will need them to prepare a report stating two important things: one, the nature of the tasks that you must do as part of your job, and two, the nature of your disability and how it prevents you from performing the specific task of your occupation. This has to be extremely specific. Often, your doctors also need to provide a rebuttal to the opinion reached on the paper review.
Because insurance companies are so suspicious of CFS and Fibro claims, the letters from your doctors supporting your claim will be extremely important. Any studies or reports that you may have in your file will be helpful in documenting your disability. Your doctor simply stating you are disabled is NOT good enough. How and why you are disabled needs to be addressed.
If you are being treated by physicians who are specialists in CFS and/or Fibro, include their CV's (Curriculum Vitae) with the letter. We have had cases where the paper reviews were conducted by medical professionals who had absolutely no knowledge of CFS and/or Fibro, and we were able to refute the termination based on their total lack of knowledge.
Disability insurance is a complex area of the law, and it is not easily managed by people who do not have experience in the area. Our firm has represented lawyers - even insurance lawyers - who found themselves overwhelmed by the complexity, the time limits and the uphill battle that fighting a disability claim termination and denial presents. If you have questions, call our office at 877- LTD-CLAIM (877-583-2524) to learn how we can help.
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