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What rights do you have when your ERISA-governed long term disability claim is denied?

May 5, 2023

When an ERISA-governed long term disability claim is denied, clients have several rights and options to challenge the denial and seek the benefits they are entitled to. Here are some of the common rights and avenues available to clients:

Right to Appeal: ERISA requires insurance companies to provide claimants with the opportunity to appeal a denied long-term disability claim. Clients have the right to submit an appeal, typically within 180 days of receiving the denial notice. The appeal process involves providing additional evidence and arguments to challenge the denial and convince the insurance company to reverse their decision.

Access to Claim File: Clients have the right to request and review their claim file, which includes all the documents and information used by the insurance company to evaluate the claim. This can help clients understand the basis for the denial and identify any discrepancies or errors in the evaluation process.

Right to Legal Representation: Clients have the right to hire an attorney to represent their interests throughout the appeals process. An experienced ERISA attorney can provide expert legal advice, assist with preparing a strong appeal, and advocate on behalf of the client to challenge the denial.

Right to Independent Medical Examination: Clients have the right to request an independent medical examination (IME) at their own expense to obtain an unbiased medical opinion supporting their disability claim. This can be a valuable tool to challenge the insurance company's medical evaluations and provide additional evidence of disability.

Right to Sue: If the appeal is unsuccessful and the denial is upheld, clients have the right to file a lawsuit in federal court to challenge the denial. This allows for a de novo review of the claim, where the court considers the claim anew and is not limited by the insurance company's decision.

Right to Damages and Attorney's Fees: If the client prevails in court, they may be entitled to receive past-due benefits, future benefits, interest on overdue benefits, and attorney's fees. ERISA provides for these remedies to incentivize insurance companies to properly evaluate and decide disability claims.

It's important to note that the rights and options available to clients may vary depending on the specific circumstances and the terms of the ERISA-governed plan. Consulting with an experienced LTD attorney, like Jonathan T. Macedo, can help clients understand their rights, navigate the complex appeals process, and maximize their chances of obtaining the long-term disability benefits they deserve.