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Long Term Disability Traps: Trap #3 Failure to Obtain the Claim Record

Posted by David P. Martin | Jul 14, 2020 | 0 Comments

Many people have long term disability benefits through their workplace, but it is only helpful if it actually insures what you think it insures. Over the next few weeks, we'll be discussing long term disability traps. A trap is a device that catches you unaware. These traps deal with time limits, the definition and location of the occupations which you are able or unable to perform, earnings qualifiers, and others.

The third trap is failure to obtain the claim record before you file a lawsuit.

You have the right to a decision that specifically sets out the reasons why your claim has been denied, but you also have the right to obtain the claim record. Sometimes, clients and referral soures say that they did obtain the claim record; however, they failed to obtain the latest claim record before filing a lawsuit.

The reason that it is important to obtain the latest claim record before filing a lawsuit is that is the version the court will consider. If you obtain the claim record at an earlier point in time than the last appeal decision by the insurer, claims administrator, or plan administrator, then you don't have the latest claim record on which they based their decision.

Many claim decisions are made with boilerplate language that states “there's insufficient evidence to prove that you are disabled under this plan.” What does that mean? Who knows? But, it will be harder to determine if you do not obtain the latest claim record on which they based the decision.

In most cases, when you present your appeal to the insurer, claims administrator, or plan administrator, they will take that information and send it to a physician who doesn't do anything other than sit in an office, review insurance company files, and issue the opinon that the insurance company wants, or they may give an honest opinion but one that is misinformed or involves a misunderstanding.

If during your appeal, that peer review by the physician makes its way into the claim record, and you don't have a copy, then you might think you have a rock solid case and fail to craft your lawsuit accordingly. This will also give you the opportunity to counteract the information and clarify for the insurance company, claims administrator, or plan administrator that there is an obvious mistake. In some cases, if you challenge reviews such as this before you file a lawsuit, there is a chance you could rectify the matter with the insurer.

Otherwise, the court is left with a record that contains an unchallenged peer review, and you are never given the chance to challenge it. Always obtain the latest claim record before you move on with litigation.

If you or a client have been caught in this trap, you need the help of an experienced ERISA attorney. Whether you or your client needs advice before applying or appealing for ERISA benefits such as long term disability, short term disability, life insurance, pension, or retirement, contact an experienced ERISA disability attorney or long term disability lawyer at The Martin Law Group at 800-284-9309.

The information presented in this video should not be construed to be formal legal advice nor the formation of a lawyer/client relationship. Therefore, no information of any kind that you provide us before such a relationship is created is confidential or privileged.

About the Author

David P. Martin

Senior & Managing Attorney


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