Frequently Asked Questions (FAQs)

• What is an "administrative appeal?"

  “Administrative appeal” refers to the insurance company’s internal appeal process. An administrative appeal is your chance to persuade the insurance company that they were wrong to deny your claim. In most cases, this means giving them additional evidence to show that you do meet the policy’s requirements for entitlement to benefits. Winning at the administrative appeal stage is the quickest way to recover your benefits, but you should never rush an appeal. 

  Three things are important about most administrative appeals:  

  1. They are mandatory. You must give the insurance company a chance to correct the error it made when it denied your claim;  
  2. They have a deadline. Internal appeals must be filed within a set period, usually 60 days after you receive a life insurance denial or 180 days after you receive a disability benefits denial. If you miss this window and fail to file an administrative appeal, your claim is over. You cannot file a lawsuit because you have “failed to exhaust the administrative process;” 
  3. They are your last chance to add additional evidence to prove your claim. You might be tempted to file a quick appeal just to exhaust the administrative process with the insurance company, and plan to plead your case more fully to an unbiased judge if your appeal is denied. But that’s a mistake. No matter how biased, dismissive and unfair you feel the insurance company is being (usually with very good reason), you cannot bypass them to get to a judge. That’s because in most cases, the judge will only consider evidence that the insurance company had a chance to consider first. If you want a chance to explain anything to a judge, you must first show it to the insurance company.  Don’t rush your appeal.

• What is ERISA?

  Most disability and life insurance policies that are sponsored by an employer are subject to ERISA. ERISA stands for the Employee Retirement Income Security Act, which became law in 1974. Government-sponsored plans are exempt (because Congress loves passing laws and then exempting themselves from following them), as are churches and some Short-Term Disability (STD) policies that function as an extension of the company’s payroll plan. But most people who have benefits through their employer will find that ERISA governs their claims.  

  The Department of Labor (DOL) has written and re-written regulations for how insurance companies must handle claims in order to comply with ERISA. Although your appeal will focus mainly on why the insurance company’s decision to deny your claim was wrong, if the appeal is denied, then your lawsuit can also explain to a judge why the insurance company failed to follow the DOL-mandated process in deciding your claim, issuing the denial letter(s), and/or managing your appeal. 

• Can I appeal on my own?

  YES. While ERISA regulations allow you to appoint an authorized representative for your claim, you are not required to go through any third party to file your claim or appeal. You, the claimant, can appeal directly to the insurance company.

  If you do appoint an authorized representative, it can be anyone you choose – from a seasoned ERISA expert, to someone with no ERISA experience, or anyone in between.

  The better question is whether appealing on your own is best for your claim. In some cases, it is. While we recommend that everyone with a denial letter contact an experienced attorney for a free case evaluation, the result of that evaluation can be disappointing. You may be told that your claim is “too small” to hire an attorney. But that does not mean you don’t have a valid claim and should abandon your appeal. If your claim was denied because the insurance company needed your most recent MRI, for example, and your doctor’s office failed to send it, you could work with your doctor to fix that on your own for a successful appeal. Even if your claim is relatively small, every dollar helps, right?

  On the other hand, there are many times when your claim denial is so complicated and so inconsistent with your medical records that it is clear the insurance company has laid out a minefield and is hoping you will step on something that will kill your claim for good. In these cases, it can make all the difference to have an experienced guide who knows where to step – and where not to step – to position your claim for ultimate success.

  How to tell what’s best for YOUR claim? First, make sure you understand your denial letter. Use our free guide, Recover Your Benefits, as a resource to make sure you can pick out “we asked for your MRI and didn’t receive it” from “we think you are lying and your doctor is incompetent” when it comes to the reasons why your claim was denied. Second, decide what your claim is worth and how much time and energy you can devote to an appeal. If you know you will not be able to give your appeal your best shot, in the long run it may make more sense for you to hire someone to help. 

• What are the chances of winning an insurance appeal?

  Better than you might think. The appeal process can be long, complicated, and incredibly frustrating, but still ultimately successful. So, as you get started, plan to hang in there until the end. Don’t give up!

  For any given claim, the odds of success depend on why the claim was denied in the first place and whether the claimant can add the evidence the insurance company says is necessary to prove the claim.

  For example, if the insurance company denied a claim because they asked for an MRI report and didn’t get it, in theory, the appeal can be as simple as providing the MRI report. In practice, the “long, complicated, and frustrating part” comes in when:

  • Your doctor’s office says they sent the MRI report, and the insurance company says they never got it.
  • You request your copy of the MRI record from your doctor’s office, but it takes multiple requests to get it.
  • You send the MRI records to your appeal manager, but the appeal manager says that the records only contain a summary of the MRI in your office visit notes with your orthopedic surgeon. Turns out, the insurance company requires the actual MRI report from the radiologist who performed the MRI. Now you understand the source of the original confusion, but you still need to fix it. So, you contact the radiologist’s office to request a copy of their records.

  This process goes on until you give up in frustration (which doesn’t bother the insurance company one bit since they can easily deny your appeal), OR the insurance company finally receives the records they need. In that case, assuming the MRI results support your claim, it’s highly likely you will win the appeal.

  Every claim is different, and there are many, many variations on this theme, depending on why your claim was denied. Sometimes, though, even after you supply the missing information, you’ll get a new letter from the insurance company explaining that the new evidence still doesn’t prove your claim. They come up with another reason for the denial and offer you a chance to respond. Then you’re back to the drawing board.

  When you appeal, whether you do it on your own or with a representative, be prepared to hang in there through this long process. In the end, no matter how long or hard it was to get there, when you provide the “proof of claim” the insurance company said was missing, it is possible to win your appeal.

• Is winning an appeal more likely if you have a representative?

  If a representative helps you build a stronger appeal than you could on your own, then yes, that increases your chances of having the insurance company reverse its decision to deny your claim.

  But all things being equal, assuming you understand very well what the insurance company needs to see in your appeal, for a claim governed by ERISA it should make no difference whether you submit your appeal on your own, or whether you authorize someone else to submit it for you. ERISA law says so.

  Disability and life insurance plans have an “obligation to establish and maintain reasonable claims procedures.” They must ensure that “the plan provisions have been applied consistently with respect to similarly situated claimants.” In other words, the insurance company must treat all similar claimants the same, unless there is a specific and valid reason not to do so. Treating an appeal differently because it was submitted by a representative instead of a claimant would not be a reasonable claim procedure.

  Even if you’ve been unable to hire a representative, that does not mean your appeal is doomed. There are many good reasons to get some help with your appeal, and even to hire an authorized representative to submit it for you. But getting favorable treatment by the insurance company shouldn’t be one of them.

• Is the "Free Guide" really free?

  YES – our free guide, Recover Your Benefits: Keys to Successfully Navigating the Disability or Life Insurance Appeal Process is free to download and print on your own.

  Download a free PDF version

  If you’d rather have a printed paperback or eBook version, Recover Your Benefits is also available for a fee at Amazon.com.

  Paperback Version

  Kindle eBook Version

  Recover Your Benefits: Keys to Successfully Navigating the Disability or Life Insurance Appeal Process covers how to read a denial letter and plan an appeal, and is useful information for everyone with a disability or life insurance claim, whether you appeal on your own or go on to hire a consultant or representative.

  Recover Your Benefits de-mystifies the appeal process by explaining why denial letters are written the way they are, what to look for in yours, and how to plan an effective appeal. Especially if you discover that the reason for your claim denial was actually pretty straightforward – such as a missing medical record or test result – our free guide may be all you need to appeal successfully. If you need or want more help, we have several paid options, starting with our personalized Strategy Session.

• What is a Strategy Session, and what does it cost?

  Our personalized Strategy Session is designed to be the optional next step, usually after you review Recover Your Benefits.

  Recover Your Benefits explains denial letters and appeals in general. Particularly when your claim is complicated, it can be helpful to review your individual denial letter with an expert to make sure you’re clear on precisely why your claim was denied and to brainstorm ideas for how to respond in an appeal. That’s what we’ll do in a Strategy Session. 

  The Strategy Session starts when you upload your denial letter and provide some basic information about your claim. We’ll review all that and note, for example, where the insurance company may have cherry-picked your medical records, what they’ll need to see in an appeal, whether and where your doctor needs to weigh in, and anything else specific to your claim. We’ll send you a written initial report on what we found, along with a personalized template for your appeal to get you started.

  Next, we’ll review the initial report with you by phone, video chat, or email to make sure we answer all your questions and to brainstorm about how to discuss your appeal with your doctors. After that call, we’ll revise your personalized appeal template, if necessary. You’ll leave the Strategy Session with a clear plan for your appeal and a full understanding of how to execute it.

  A Strategy Session is $395. If you’d like to continue working with us during your appeal, we can discuss options for Appeal Coaching and/or Appeal Management. 

• This all sounds complicated. Will you just handle the appeal for me?

  We hear you. As much as we try to de-mystify the appeal process to show you the right next steps to take, there’s no escaping the fact that for most claims, there are a LOT of steps to take. If you’d rather have us handle more of the work, coaching you or even acting as your representative with the insurance company, we are happy to offer those options.

  We still recommend you start with our free guide, Recover Your Benefits, and that you ask an experienced attorney for a free case evaluation to understand all your options. 

  Then, if necessary, continue with a Strategy Session. Even when your denial letter seems incomprehensible, sometimes that’s really all you’ll need to make the appeal seem more manageable. If nothing else, it makes you an educated consumer in a process that, if you’re like most people, you never thought you’d need to know much about. A personalized Strategy Session, which includes a customized appeal template to get you started, is $395.

  Our most popular option after a Strategy Session is Appeal Coaching, where you keep us in the loop as you gather additional evidence and draft your appeal. We’ll review your new evidence and your appeal draft and give you feedback and advice before you submit everything to the insurance company. As the insurance company reviews your appeal, we’ll be here to discuss any letters they may send you asking for more time, more evidence, an in-person examination, etc.

  If you win your appeal, we’ll coach you through the first insurance company claim review after the appeal. If instead, you receive a denial letter, we’ll conduct a new review and Strategy Session with you to plan the next steps. Comprehensive Appeal Coaching is $995 and includes as many emails, phone calls, appeal plan changes and appeal letter revisions as necessary while you gather your appeal evidence. We finish with a Final Appeal Review Package to take you through the appeal decision.

  Learn more about all our Appeal Coaching options at our Services page.

  Finally, if you just want to be DONE with the insurance company, with Appeal Management we’ll take charge of the appeal for you. We’ll notify the insurance company that we are acting as your Authorized Representative, and we’ll take it from there. You’ll still need to work with your doctor to collect support for your appeal, but we’ll help guide you and take care of the rest – including reviewing your claim file, developing a detailed personal statement, and writing and submitting your appeal letter. The cost to have us act as your Authorized Representative is $3,995.

• Do you handle health insurance appeals?

  No. Like disability and life insurance, health insurance is also often part of an ERISA-governed employee benefit plan. While there are many similarities between these denials and appeals, there are also significant differences. Our expertise is in disability and life insurance claims, and we recommend our colleagues at Fix My Claim (https://fixmyclaim.com/) for expert advice and management of health insurance claims. They have a similar flat-fee cost structure that makes getting help with your health insurance appeal personalized and affordable.

  

• Do you handle Social Security Disability (SSDI) cases?

  No. Unlike employer-sponsored long-term disability (LTD) plans, SSDI is separate from ERISA. While some underlying issues are the same between LTD and SSDI, especially in that both require you to show you cannot work and meet the applicable definition of “disabled,” SSDI is an entirely separate program. Our experience and expertise are in navigating the LTD appeal minefield. Your local Social Security office can provide a list of qualified Social Security Disability representatives near you.

• Do you offer a free consultation?

  We are always happy to hear from you by phone or email and will answer any questions you have about our company and services. There’s never any charge for that.

  We also recommend that everyone with a denial letter contact an experienced attorney for a free case evaluation. Even when the attorney cannot represent you, understanding why can help you plan the next steps for your appeal. 

  Keep in mind that most free case evaluations are also for the benefit of the consulting firm to decide whether they want to take your case on a contingent fee basis – or not.

  We’re different. We are not a law firm, and we are not trying to assess your case to see whether we want to take it on a contingent fee (“we only get paid if we win”) basis in exchange for a percentage of your benefits. We won’t judge your claim value to be “too small” to work with us. It doesn’t matter whether or not you have been approved for SSDI yet, or whether a decision is pending. We don’t need to see additional test results or a note from your doctor first to decide whether or not we will help you with your appeal. If you have a denial letter and want to appeal it, we are here for you, period.

  Our free guide, “Recover Your Benefits: Keys to Successfully Navigating the Disability or Life Insurance Appeal Process,” may be all you need to decipher your denial letter and plan your appeal yourself. If you want personalized input, our next-level $395 Strategy Session is designed to address all your questions, plan for your appeal, and get you started with a templated appeal letter draft.

  There is never any charge to start a Strategy Session. Send us a copy of your denial letter from the insurance company, and some background information about your claim. We’ll send you a report about what we see as your next steps and a detailed description of what we can cover in your personalized Strategy Session. We’ll identify areas where we think you will need to dispute the insurance company’s version of your claim, as well as places where we think you’ll need to add additional evidence. You decide whether to proceed to a full, paid Strategy Session. 

  And if you want us to stay engaged to coach you through the appeal, or manage the entire appeal for you, we have options for that. Learn more at our Services page. 

  Let’s start with the Recover Your Benefits and, if necessary, a Strategy Session and then decide your next best steps from there. 

  Still have questions? Please Contact Us and we’ll do our best to answer.

Read More