It’s the crystal ball question that’s first on everyone’s list. No matter how you approach it, a disability appeal is an investment. At a minimum, every appeal is an investment of your time, and it can be a lot to ask of your doctor(s). If you get help with the appeal – which nearly everyone needs to some degree – you’re either asking for time and energy from your family or friends, or you’re spending money on a consultant or a representative. If you’re not paying out of pocket up front, you know you’ll be paying more down the road, with a significant reduction in your net disability benefit if you do win.
If you knew you would win, it would all be worth it. At the same time, if you knew the appeal would be denied, you might save yourself the time and trouble and expense. (Although, before you made that decision, you would need to look even further out to what the resolution to a lawsuit would look like if your appeal is denied. Winning in court or settling a lawsuit to get some of your benefits can make your initial investment in the appeal worth it after all.)
So, the question makes perfect sense: will I win my disability appeal?
Unfortunately, as you probably already know, no one can tell you for sure. Even the insurance company, who will make the appeal decision, can’t tell you now how the appeal will turn out even if they wanted to (spoiler alert: they don’t want to). That’s because for almost any given case, it would be possible to win the appeal with the right evidence OR lose the appeal for a variety of reasons.
Let’s unpack that.
A successful disability claim isn’t about being disabled. It’s about proving that you’re disabled. It’s unfortunately possible to have a medical condition that prevents you from working (as your disability policy requires) without being able to provide proof of that (which your policy also requires). No proof = no benefits, even if your medical condition does prevent you from working. Most initial disability claims that are denied need to counter this “no proof” argument from the insurance company.
Every winning disability appeal has something in common: the evidence presented on appeal satisfied the insurance company’s standard for “proof of claim.” If you have no new evidence to present, your appeal is easy: just send the insurance company a letter (or fill out the form they give you), saying “I appeal.” They are required to take a second look at the evidence that’s in your file already. And the odds are overwhelming that you will lose. It’s exceedingly rare that insurance companies will back down from their “not enough proof” argument just by re-reviewing the same evidence they said was insufficient the first time.
It’s easy to lose an appeal. But how do you win one?
At the core of your appeal, you need evidence that proves you meet the policy definition of disabled. The insurance company doesn’t have to prove you can work. You have to prove you cannot. Unfortunately, that leaves a lot of room for the insurance company to deny claims and appeals on some very shaky grounds. It can seem like no matter what evidence you present, the insurance company will stamp it as “insufficient proof” and deny your claim. But here’s what it takes to give your disability appeal the best chance possible:
- Winning evidence can be office visit notes from a medical professional that show you are receiving treatment for a medical condition that caused restrictions and limitations which prevent you from doing your job duties. The more you can rely on “objective evidence,” like physical examination and test results, to explain your restrictions and limitations, the stronger your appeal will be.
- Other winning evidence for an appeal can be a formal job description that shows your job duties were different and more demanding than the insurance company said they were.
- It’s always helpful to have a treating physician on your side who will respond to the medical analysis in the denial letter and explain why the insurance company is wrong.
- It’s also helpful to give the insurance company the full context for your claim. Explain what happened to you to put you out of work. Include statements from any work colleagues and close contacts who can support your claim. Make sure your appeal letter fully explains why you meet that policy definition of disabled.
By collecting all this evidence, you will be putting together an appeal that SHOULD win. That’s really all you can control. And often, that’s enough. In the face of a strong appeal, the insurance company reverses their earlier decision and approves your disability claim. You win!
Unfortunately, though, the same insurance company who made the wrong decision about your claim initially will be also deciding your disability appeal. And they have certainly been known to make the same mistake twice. So even after all that work to put together an appeal that should win, you may lose.
But when you put together a disability appeal that should win, even if you lose the appeal, that’s often not the end for your claim (the way it would be if you just said, “I appeal” and left it at that). Appeals that should win are usually strong cases for litigation. Filing a lawsuit is no one’s first choice – for one, it will be a whole lot slower than winning the appeal (sometimes years slower). And legal fees will certainly reduce your total recovery amount. But on the scale of bad options (which you had the misfortune to step on as soon as you were unable to work), recovering something for your disability claim is better than nothing.
There’s just no way for anyone to answer, “will I win?” A better question is, “should I win?” The answer to that depends on:
- Whether your doctors and your treatment records explain what your restrictions and limitations are;
- Whether your job description includes things that you cannot do because of your disability; and
- Whether your appeal letter presents the context for your claim, explaining what happened and why you can’t work, in a way that “makes sense” to the insurance company.
If you have these three basic elements, then absolutely you should win your disability appeal. And that happens a lot – insurance companies do reverse their disability denials when faced with strong supporting evidence that they made the wrong call. But even if they don’t in your case, and your appeal is denied, you’ll have good reasons to continue your fight for benefits in litigation.
In order to put together a winning appeal, you need to understand the appeal process and have a clear picture of what your denial letter is really saying about why your claim was denied. Insurance Appeal Consultants can help with both of these, at no charge. Visit our Free Denial Letter Review page to get started. If you want our help pulling together the evidence for your appeal and writing your appeal letter, we’ll explain our options for that. But there’s no obligation to receive our initial assessment. Sometimes that’s all you need to build an appeal that SHOULD win, and DOES win. We’re rooting for you!
