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Long Term Disability Traps: Trap #4 New Evidence Considered on a Final Appeal

Posted by David P. Martin | Jul 20, 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 fourth trap is new evidence considered on a final appeal.

When the insurance company begins considering your claim, they may ask nurses or doctors to review the information in your claim record to see if paying the claim is warranted under the plan terms. If your claim is denied, the insurer is supposed to give specific reasons as to why your claim has been denied. You then have the right to obtain the claim record on which they based their denial.

Upon your review of the claim record, you may notice that the reasons why the claim has been denied
are all wrong, and you can prove it. You then set about proving and obtaining all of the evidence necessary to win your case, including but not limited to:

  • Statements from treating physicians
  • Information pointing out that the person who denied the claim misunderstood the information
  • Statements from coworkers
  • Expert testimony from vocational experts or independent physicians

Here's the Trap…

After obtaining this information, you submit it on appeal. And this is where the trap occurs. The insurance company, plan administrator, or claims administrator may look at your appeal and see that they were wrong in denying your claim based on the original reasons laid out.

However, often times, they will then present new evidence or new reasons to deny your claim that you've never seen or had the opportunity to address.

Once your claim is denied again, they may instruct you to file a lawsuit to obtain your benefits. If you have read our post on the third long term disability trap (Long Term Disability Traps Trap #3: Failure to Obtain the Claim Record) and obtained your final claim record, you may only then see the new reasons or new evidence they used to generate an entirely new decision on the final appeal.

How to Get Out of This Trap

Experienced ERISA counsel will know what to do when this happens and will demand the right to be able to respond to any new evidence considered or any new reasons to deny the claim.

If you go to Court without trying to rectify this trap, at best, the Judge may require the case be remanded back to the insurance company, and at worst, the Judge will say that you should have done something about the new evidence before you filed a lawsuit.

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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