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. (Pro tip: if you do choose an authorized representative, choose someone with a LOT of administrative appeal experience.)

  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, unfortunately 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 or that you should abandon your appeal. It just means that the amount at stake is not large enough to afford full contingent-fee (“only pay if we win”) representation. 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 (we can help with our Free Denial Letter Review). Then, 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. Finally, 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.

  Also read our article, Will I Win My Disability 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 contingent fee (“only pay if you win”) 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 Disability Appeal Planning Session.

• Is the "Free Denial Letter Review" really free?

  YES – send us your insurance company denial letter and answer a few questions about your claim. We will review it and send you a written report on what we find. For free.

  We’ll 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.

  Get started on your free denial letter review here.

  A free denial letter review tells you WHAT to do for your appeal based on the information in your denial letter. Our free guide, Recover Your Benefits: Keys to Successfully Navigating the Disability or Life Insurance Appeal Process tells you HOW to do it. 

  Together, they may be all you need to take the next steps and build your appeal on your own.

  Once you know WHAT to do and HOW to do it, you may want our help getting started or getting all the way to the finish line. For that, we have several paid options, starting with our personalized Disability Appeal Planning Session. Read more about how to continue working with us on the Services page.

• What is Appeal Coaching, and what does it cost?

  Our personalized Appeal Coaching is the optional next step after our free denial letter review (which told you WHAT to do for your appeal) and Recover Your Benefits (which told you HOW to do it). 

  Appeal Coaching starts with a Planning Session. We’ll review the initial denial letter 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. We’ll tell you what to include with your appeal letter, and what to ask for from your doctors and other appeal supporters. We’ll answer all your questions about what to expect and what to do to finish the appeal on your own. You’ll leave the Disability Appeal Planning Session with a clear plan for your appeal and a full understanding of how to execute it.

  When you have gathered your evidence and written your appeal, send everything back to us for a final review. We’ll suggest edits if necessary and compile everything into a single PDF for you to send to the insurance company. Coaching continues until the insurance company issues a final decision on your appeal. And win or lose, we’ll help you plan for what’s next.

  Appeal Coaching is $495. 

• This all sounds complicated. Will you just write 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, including writing the appeal and any other letters you’ll need to send to the insurance company, Appeal Writing is for you.

  We still recommend you start with our free guide, Recover Your Benefits, and a free denial letter review. Then, if you choose to keep working with us, Appeal Writing is $995.

• Do you handle Veterans Affairs (VA) disability claims?

  Yes, Ellen is a VA Accredited Claims Agent. Our main focus is helping veterans who also have STD/LTD claims. To discuss your VA disability claim, please Contact Us.

• 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 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.

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