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Chronic Fatigue Syndrome, Long Term Disability Insurance Claims and the Appeals Process

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By Justin Franke and Jason Newfield, Attorneys at Law • www.ProHealth.com • July 20, 2014


Chronic Fatigue Syndrome, Long Term Disability Insurance Claims and the Appeals Process
Long term disability insurance companies have a well-deserved reputation for delaying and denying claims from ME/CFS patients. Not a pleasant fact, but true. Understanding the claims process and the appeals process that follows may help take the sting out of what seems like a personal rejection.

Delaying or denying claims for ME/CFS patients is a routine matter for LTD companies, as this condition is still considered to be a syndrome and not an illness. That’s the first challenge. Medical records that clearly document not only your symptoms, but the way in which they prevent you from performing the specific tasks of your occupation must be clearly detailed.

Usually the first response to an ME/CFS claim is a request for further documents. We know that the last thing that you want to deal with is information requests from the insurance company. If you are too ill or upset by the request to respond, we recommend having a trusted friend, family member or a legal representative review the correspondence and help you answer it within the required time frame.

Be aware that there are very strict time limitations throughout the entire claims process, and not responding at all, or responding late, may put your claim in jeopardy. If you are unable to cope with the stress, or if the stress further exacerbates your illness, again, ask someone you trust to help you.

Keep records of all and any contact with the insurance company. Keep a copy of all documents sent to the insurance company, and send them with a delivery service – it doesn’t matter which one - that requires a signature that proves delivery took place. Phone calls do not properly document issues – letters and correspondence, even email, do so more effectively.

If your disability insurance policy is part of your employee benefits package, it is likely governed by ERISA, a federal law originally intended to protect retirement plans from being misused by employers. Today ERISA is one of the insurance companies’ biggest weapons used by insurance companies against paying out claims to disabled insureds.

Under the terms of ERISA, if your claim is denied, your only option is to file an appeal through an administrative appeals process in which the insurance company itself serves as judge and jury. If that appeal is unsuccessful, then an insured gets the key to the Courthouse. However, in litigation, the only “evidence” allowed to be considered by the Court, in most circumstances, is the information contained in your claims file. That is why it is so important to provide the insurance company with materials that will support your claim, as it is also the body of information which the Federal Judge will be limited in considering. Your file must contain all relevant medical information, physicians’ notes, studies and reports. This material needs to provide an articulation of the functional deficits and/or limitations that one suffers as a result of the disabling condition.

It must be noted that a heart-felt letter from a person to an insurance claims adjuster that attempts to explain why the adjuster has misunderstood the claim is not going to work and may cost valuable time and ultimately prejudice your ability to succeed in litigation. Pleading with an adjuster to help because your family depends on your income or disability benefits to pay the mortgage will also not get the response you want. The response to the denial letter is a part of your legal defense and must be carefully and strategically managed.

We have represented lawyers, and even insurance lawyers, who felt that their experience with fighting claims in other areas of the law would help them fight the disability insurance company. This is a very different area of the law.

If your disability policy is a private or individual disability policy that you purchased on your own, you do have the option of taking the insurance company to court without having to engage in an administrative appeal.

Whether you are fighting a claim under an ERISA dispute or an individual policy, you will want to retain an attorney with experience in two areas: disability insurance disputes and ME/CFS claims. The attorney who has extensive experience in both areas understands the special challenges posed by an ME/CFS diagnosis with respect to a disability claim.

Long term disability insurance claims for ME/CFS patients are challenging, but not impossible. Proper documentation, timely responses to requests and an understanding of the processes will help build a foundation that will assist in defending your claim. Remember that once you are on claim, there will continue to be requests for information and evaluations. If you have questions, call our office at 877-LTD-CLAIM (877-583-2524) to learn how we can help.


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