You are here: Home Insurance Disability ... Disability ... Summary
Information about all aspects of finances affected by a serious health condition. Includes income sources such as work, investments, and private and government disability programs, and expenses such as medical bills, and how to deal with financial problems.
Information about all aspects of health care from choosing a doctor and treatment, staying safe in a hospital, to end of life care. Includes how to obtain, choose and maximize health insurance policies.
Answers to your practical questions such as how to travel safely despite your health condition, how to avoid getting infected by a pet, and what to say or not say to an insurance company.

Summary

If your claim that you are disabled within the meaning of your disability income policy is turned down, get:

  • The denial in writing.
  • An understanding of the insurer's appeal process.
  • The date by which the appeal must be made.

Consider hiring an attorney to do the appeal, or at least to advise you and review your documentation. A lot of money may be at stake.

If you go it alone, take the following steps. For details about each step, click on the link.

To Learn More

More Information

Disability Insurance

Step 1. Find Out Why Your Claim Was Denied

When an insurance company denies a claim for disability, it will send a letter which should give the reasons for the denial, although the reasons stated may be somewhat vague.

Make sure you understand the exact reason(s) why the claim was denied. Often the denial letter is not specific -- it will say something like "lack of medical documentation."

If you have any questions, call the claims person and discuss it - in as friendly a manner as possible. Consider acting confused, not angry. Once you know the general area, you can ask follow-up questions to determine specifics to help you determine what you need to do. Following are some common reasons why claims are turned down, and what to ask:

  • Missing or incomplete medical records about your medical condition.
    • Which records were used? For what dates?
    • If medical records are missing, what is missing?
      • Is the company missing your therapist's records when mental issues were a major part of your symptoms?
      • Did the records fail to include some lab tests or an outside specialist's comments?
      • Did your doctor use only a word or two to describe your symptoms or fail to include some symptoms in the notes?
  • It's not clear whether you were able to perform work described in the plan.
    • What occupation did the insurer use?
    • What job description did the insurance company use?
      • In general, was the description accurate and complete? Did the insurer think you were a classroom teacher when you only taught one class but were also the wrestling coach?
      • Did the insurer's description of what is done in the job reflect your job, or just a generic version of your job? Sometimes, the employer pulls out a pre-printed description that is so generic it could fit every employee - and not describe your job at all. Sometimes, the insurance company will switch from your actual occupation to the one in their occupational guidebook (every claims office uses one) and judge your disability on the job that is spelled out in the book - even if it's wrong.
  • Was there insufficient proof about your symptoms?
    • It is particularly difficult to prove symptoms that cause your inability to work when they are largely subjective.
    • Pain and fatigue are two symptoms that are particularly hard to use in support of a claim.
  • Is there a claim that there was no coverage?
    • If the company maintains that there is no coverage, find out which policy provision they are relying on to deny your claim.

Step 2. Focus On The Deadline For Your Appeal

Deadlines are serious. If you miss the deadline, you may lose your right to appeal.

The letter denying your claim will usually tell you how long you have to appeal.

Make an alert to remind you of the deadline date set by the insurance company.

Employer-based group disability insurance policies follow the rules described in the federal law known as ERISA. Most individual policies follow the same rules.

Under ERISA:

  • You have 60 days to appeal.
  • The insurance company then has 60 days to review the claim -- which can be extended for up to another 60 days if needed. The person or people who handle the appeal must be higher up than the person that denied it originally.

It is advisable to get to work right away to be sure to meet the deadline.

To Learn More

More Information

ERISA

Step 3. Adopt A Positive Attitude And Put Reason And Thought Into All Your Contacts And Letters

This can be a very stressful time, so try to keep as positive an attitude as possible. Assume that the insurance company just didn’t have the right information and that you can supply it. If you start considering this to be a battle against “evil forces” who are “plotting to keep you poor which they get rich” your frustration level will only increase. Your appeal won’t be the reasoned and rational response needed to win your claim.

Put reason and thought into all your contacts and letters. Insurance companies know that the emotional, enraged, and out-of-control person is likely to burn out and give up. By staying calm and rational, you are letting them know you are in for the long haul.

Step 4. Obtain New Information

The insurance company is not likely to change a decision using the same information that was used to deny the claim. You're going to have to either provide some brand new information or show a brand new way to look at what the insurance company already has.

Consider:

Medical records

Look for additional material from a doctor whose records the insurance company didn't have. Keep in mind the records we're talking about relate to the date you claimed you became disabled, not from the time of your appeal.

Subjective symptoms

If part of your disability claim is based on pain or fatigue, provide more proof about your symptoms and the effect they have had on your work and on your daily life.

  • If you've kept a Symptoms Diary, make sure everything was listed - particularly how each symptom affected your work and/or daily life. If you haven't been keeping a diary, this is a good time to start keeping one. At the least, it will be helpful for future doctor appointments. To learn more, see: Symptoms Diary.
  • Obtain written statements from family and/or friends.
  • If there were performance problems at work, there may be memos in your personnel file. Your supervisor can provide excellent support if your performance was suffering and he or she can document that fact either through past performance reviews, warnings or a letter. If there is no existing documentation, see if your supervisor would be willing to write an affidavit now describing your symptoms and the effect they had on your work. See: Statements from Supervisor and Co-Workers, below.
  • If it hasn't been done before, now is the time for your doctor to take the time to write a multi-page letter. See "Letter from your physician", below.

More accurate job description

  • Consider obtaining an affidavit or at least a letter from your supervisor or the HR department that explains all the "material" duties of your job.
  • It would be particularly helpful if the affidavit or letter and clarifies the tasks that your symptoms prevent you from doing.

Letter from your doctor

  • If it wasn't done before, now is the time for the doctor to take the time to draft a very complete (usually multi-page) letter that explains, from a medical point of view, why you are unable to perform your job. Keep in mind that the insurance company needs to see more than a statement that says: "I'm a doctor. I say she's disabled. Therefore she's disabled."
  • The letter should be written as if it is directed to another medically trained person.
  • The letter should include details geared to change the opinion of the insurance company such as an analysis of lab results showing a different conclusion than the insurance company reached, or an elaboration on progress notes expanding on the symptoms you've encountered.
  • If the insurance company points to a particular capability that you deny, it would be helpful for the doctor to address that subject directly.

Statements from co-workers and supervisor

  • If you were having trouble doing your job, your co-workers and supervisor were in the best position to see it. An affidavit or at least a letter giving anecdotes of how they saw your performance slipping will help immensely. For example: "I have been Mary's supervisor for two years and she was always a good employee, but three months ago she started missing work and her performance when she did work deteriorated to the point I had to give her a written warning."
  • The affidavit or statement should also state how each of your symptoms affected your ability to do specific, material, parts of your job.
  • To learn more, see: Affidavits from Co-Workers.

Statements from family and friends

  • If your family observed the problems you were having and continue to have, a written statement giving anecdotes about the problems they witnessed will bolster your position. The anecdotes should be as specific as possible.
  • For example, instead of a friend writing, "John has problems with pain," it is better is they describe what the friend saw and how it affected your activities: "There were times when John's pain was so severe, he had to cancel plans to go shopping with us."
  • To learn more, see: Affidavits From Friends And Family.

Step 5. Write A Cover Letter

Once you've assembled the new material to bolster your case, write a rational, reasoned, cover letter that:

  • Includes the definition of "disability" in your insurance plan.
  • Provides an overview of your argument and the evidence. Explain how the information shows that you are indeed disabled according to the definition in your insurance policy.
  • Describe each document you're including and show how it supports your claim for disability. For example, "Included is a statement from my doctor that explains how my condition and the side effects of the medication leave me with no energy to do my work. Also enclosed are letters from my roommate, my mother, and a co-worker showing what they have seen as the fatigue got worse and kept me from doing increasingly more of the things I used to do. The letter from my co-worker shows I have difficulty lifting the boxes I need to lift at work. The letter from my roommate and mother even show I have been too tired to work on my airplane models."
  • Include in the letter that if this appeal is denied, you will continue to appeal the decision until you are awarded the benefit which is due to you. Many experts believe that insurance companies regularly deny "gray area" claims knowing that many people will accept the denial without question. They contend that letting the insurer know that you do not intend to give up will result in the insurance company reversing the denial and paying the claim. Whether or not that is true, it doesn't hurt to state your intention to press your case.
  • It will hurt, not help, to imply or say the insurance company or its employees are liars or crooks, or even that they just want to deny your claim. Without arguing the truth of any of that, don't be tempted by your emotional reaction. This is the time for just the facts, as Jack Webb would have said, the facts that support your position. The same tone and attitude you use to call your insurance company should be used in the letter as well. [See Talking to Your Insurance Company.]
  • Don't threaten the insurance company. The only effect it is likely to have is to slow down your claim because even mentioning lawsuit will mean the legal department will be brought in. Showing on your letter that a copy is going to an attorney or an advocacy group is a non-threatening way of letting the company know you intend to rigorously pursue your claim.

Indicate the copied person is an attorney by including "Esq." after his or her name or writing out "attorney at law" or the name of the law firm. Get the permission of the attorney to use his or her name. It doesn't have to be a disability insurance attorney, just an attorney, any attorney. [see Lawyers: How to Determine What Kind You Need for help in finding an attorney if you don't have one.] For example: "cc: Linda Manheim, Esq." Or "cc: Linda Manheim, Esq., Manheim, Morse, and McKenzie"

  • Show copies going to people further down the line of appeals. Call the Department of Insurance of the state in which you reside. If you don't have the contact information, see: www.naic.org offsite link. Get the name of a person who works as a consumer service worker. (While you're at it, get the person's direct telephone number so you'll have it in case you need it later.) State in your appeal letter that you are sending a copy of the appeal letter to that person at the Department of Insurance. Showing a person's name at the Department will let the insurance company know you're not going to give up. For example, after your signature, write: "cc: Keith Mitchell, Consumer Service Representative, Indiana Department of Insurance."

This should be a rational, reasonable letter. Ask an attorney or a trusted friend or family member to read it before mailing to be sure it says what you want. What you mean by using certain words may not be what readers take from them.

Send the letter in a manner that provides proof of receipt, such as U.S. Mail, certified, return receipt requested or by overnight service.

Step 6. Follow up

Call after a week or two to confirm that the letter was received, and to track the progress of your appeal. Remind the insurance company that you do not intend to stop pursuing this claim.

The appeal may take longer to review than the original claim even though the insurance company is not likely to send out for additional information. Many times appeals are forwarded to outside medical consultants. This doesn’t mean the review is any more objective than it was in the Claims Department. These consultants make good money from the insurance company. Reports indicate they are not inclined to be objective.

Step 7. If Your Appeal Is Turned Down Again, Don't Give Up

If the appeal is turned down, ask the company to consider another appeal.

  • If it agrees, follow the above procedure all over again, knowing that it is more important than ever to find new information that will change the minds of the decision makers. Without substantial new information it will be difficult to change the opinion of the insurance company since they've already denied the claim twice now.
  • Consider working with an attorney or other qualified expert to at least supervise your appeal or to take it over entirely.
  • Consider complaining to the regulatory authorities, which will probably be your state's Department of Insurance. [See Complaining to the Regulators]. This should be done even while making a second appeal. This step has not been recommended earlier because the State Insurance Departments are not always very helpful in such complaints. Departments of Insurance tend to be more helpful if the question is about the meaning of a policy provision than if the question is a disagreement about the import of medical evidence. Still, a complaint to your state Insurance Department must be taken prior to any court action to show that you have tried every means possible prior to court action.

Step 8. If All Else Fails, Go To Court

The final step is to find and hire an attorney and sue the insurance company. To learn more, see Lawyers: How to Determine What Kind You Need.