Fighting Claim Denials
Our lawyers suggest a number of steps you can take to avoid a denial (or termination) of your claim in the first place, or, in the event of a claim denial or termination, to maximize your chances that the denial is overturned and you get the life, health insurance or disability benefits to which you are entitled.
These tips for getting your life, health insurance, and disability claims approved are summarized below, but you can follow the links to a more detailed discussion of each tip. Our attorneys can provide assistance with each step, and, indeed, as noted below, getting legal advice early is one of the best ways to avoid a denied claim.
- Make Sure the Foundation for your Life, Health Insurance or Disability Claim has been Laid: Many claimants mistakenly believe it’s enough to file disability claim forms or submit requests for pre-authorization for health insurance benefits. Their doctors, employers and the insurance company will take care of the rest. In fact, however, treating physicians and employers often have very little time to devote to disability or health insurance paperwork. The insurance company, meanwhile, views it as the claimant’s burden to prove entitlement to life, health insurance or disability benefits. Therefore, a claimant should be an active claim manager, ensuring that proper records are being kept by treating physicians and that the insurance company is provided with all medical, employment, and occupational documentation necessary to support the claim. Our attorneys can guide your efforts to strengthen the support for your life, health insurance, or disability claim.
- Take Full Advantage of ERISA Internal Appeals and ERISA Appeal Rights: Unfortunately, our lawyers often see appeals handled by claimants where the emphasis has been on speed, rather than substance. A claimant may feel that his disability is obvious, or that coverage under her health insurance plan for a particular treatment is clear, and, therefore, mere reconsideration (without submitting any new evidence) will be enough to correct the insurance company’s glaring mistake. In employer-sponsored life, health, and short or long term disability plan that are governed by ERISA, this can be a major tactical error, and can seriously damage your chances for getting your disability claim or health insurance benefits approved for coverage. Our lawyers have many years of experience handling internal appeals, and can make sure you take full advantage of your appeal rights and build the best possible case for your life, health insurance, or disability claim.
- For Health Insurance Claim Denials, Consider the Possibilities of an External Appeal: Many states and medical plans offer the option for an external review of health insurance coverage claim denials. External review may be an advantageous alternative to an internal appeal, if only because the external review physicians who render the coverage determinations tend to be far more independent and objective than the in-house doctors and outside physician consultants routinely retained by insurance companies. Our lawyers can determine whether external review is the best option for you, and help you complete external appeal application. Please note that the deadline for requesting an external review may be extremely short, so be careful to observe such deadlines in a timely manner.
- Look for Evidence of Mistakes and Bias by your Life, Health, or Disability Insurance Company: Please note that in most cases, the principal burden of demonstrating your right to life, health insurance or disability benefits lies with you, the claimant. It may be fatal to your claim to point out your insurance company’s errors, without compiling substantial affirmative evidence of your disability or the medical necessity of a disputed surgery, treatment, or drug. However, if you have provided such affirmative evidence of your claim, a comprehensive critique of the mistakes made by the insurance company’s claim personnel (including disability claim representatives, nurse reviewers, in-house medical directors, and vocational consultants) can be effective in persuading the insurance company’s appeal review representative (or a court) that such mistakes are what caused the insurance company to ignore, misunderstand, or misinterpret the affirmative evidence demonstrating your right to disability benefits or coverage for your health-care claims. With many years of experience handling insurance appeals and litigation, our attorneys are familiar with the sorts of affirmative evidence needed to support your claim, and the many, sometimes subtle, errors made by insurance companies that can be used to prove their denial of your disability claim or claim for health or life insurance benefits was improper.
- Consult a Lawyer about your Health, Life, or Disability Insurance Coverage, the Earlier the Better (Even Before you’ve Filed your Claim): Our lawyers are ready to guide you at any point in your claim, from initial application, through the appeal of a denial or termination, to the final resort of litigation. However, the sooner you have legal assistance, the better. Because most people have life, health and disability insurance coverage through their employment, the federal law known as the Employee Retirement Income Security Act, or ERISA, typically governs most claims. Unfortunately, while ERISA offers many protections, it also has many potential complications and pitfalls. By the time you’ve completed an appeal on your own, an attorney may be unable to help. Consulting our attorneys early on — when you are first considering your claim application or after your benefits are first denied — is the best way to make sure that your disability claim or claim for life or health insurance benefits will be approved.
- Don’t Procrastinate About Filing a Lawsuit! Consult an Experienced ERISA Disability or Health Insurance Lawyer to Determine Whether it is Time to Sue your Insurance Company: If you have completed your internal appeals and your insurance company has notified you that your only option is to file a lawsuit, it is imperative that you do not delay. Consult a lawyer as soon as possible to determine the merits of filing a lawsuit against your insurance company or plan to compel payment of your life, health or disability insurance benefits. Your time for filing a lawsuit is limited. The law governing limitation periods (the period of time after which your right to file a lawsuit may be barred), can be extremely complicated, and most courts will enforce shorter deadlines contained in your insurance policy or plan. It is better to consult an attorney early and determine that a lawsuit is unlikely to succeed, than to delay that consultation only to find out you had a strong claim for benefits, but your lawsuit is now time-barred by the applicable limitations period. Our lawyers can help to review your case and determine whether a lawsuit can lead to a cost-effective resolution of your health, life or disability insurance claim.
Mark Scherzer Law :: Health Insurance Claim Appeals :: ERISA Short and Long Term Disability Claim Appeals
New York ERISA and Private Insurance Lawyers (including Sullivan County, Ulster County, Dutchess County, Delaware County, Greene County, Columbia County, Albany County, Rennselaer County, Clinton County, Jefferson County, Oneida County, Schenectady County, Otswego County, Saratoga County and St. Lawrence County