Employees in Chicago whose long-term disability insurance claims were denied often have a similar grievance. The insurance company relied on opinions of doctors who never examined the claimant. The most common reaction individuals have is to feel offended a doctor who never examined them would disagree with their treating doctor, who has treated them for years, or sometimes decades. When an insurer’s doctors’ opinions are at odds with your doctor’s opinions, here are helpful tips.
No matter the reason for a denial, if a long-term disability insurer denies your claim, you should ask for its file. Before filing any lawsuit under ERISA § 502(a), you must exhaust administrative remedies, which includes submitting the required appeal. ERISA’s regulations give you a right to all the “relevant” documents regarding the denial from the insurer. 29 C.F.R. § 2560.503-1(g)(1)(vii)(D) & (m). The file will help you understand why the insurer denied the claim.
While the ultimate conclusion by the insurer and its doctors is important, how they reached that conclusion is even more important. The opinions may misstate or omit evidence. Other times, the conclusions may be inconsistent with the doctor’s specific findings. Recently, in Fetter v. United of Omaha Life Insurance Co., No. 20-C-0633, 2021 WL 1842463 (E.D. Wis. May 7, 2021), United of Omaha denied Fetter’s long-term disability claim. But the insurer accepted the findings of one of its doctors, who concluded Fetter had restrictions on reaching and fine manipulation that were not compatible with Fetter’s occupation. Despite the insurer denying the claim, the court held the denial was unjustified because it did not match the reason for the denial, citing Gallo v. Amoco Corp., 102 F.3d 918, 923 (7th Cir. 1996).
Under new ERISA regulations that apply to disability benefit plans, before the insurer can issue an adverse decision after reviewing your appeal, it must provide you the new evidence it obtained. 29 C.F.R. § 2560.503-1(h)(4)(i). This gives you an opportunity to see why the insurer may uphold a denial, before it does so.
If an insurer denied your long-term disability claim, contact an experienced long-term disability lawyer right away.