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LTD denial/remand case underscores ERISA disability process

| Mar 4, 2021 | Long Term Disability Claim Denial

No one who has ever been involved with the process for long-term disability claim approval and the steps often required for getting there underscores ease in clearing all the hurdles.

Because there are routinely many of them. Moreover, successfully negotiating them mandates more than a modicum of patience and persistence. As one authoritative national legal source on long-term disability governed under the federal Employer Retirement Income Security Act emphasizes, “The process of submitting a disability appeal is far from short.”

That appeal reference is provided above because that is precisely what is involved in legions of ERISA long-term disability claims, especially those potentially headed for litigation in a federal court. The above-cited legal source stresses that a claimant failing to follow through on an ERISA-required filing of an internal administrative appeal “cannot file a lawsuit for any denial or termination that you have experienced.”

One claimant’s reported case amply demonstrates that imperative, as well as spotlights an insurer’s clearly problematic conduct. The chronology goes like this:

  • Primary care physician duly confirms claimant’s incapacitating disability to insurance company
  • Insurer (Aetna) denies claim, relying on RN’s opinion overriding the MD’s conclusion
  • Claimant duly follows through with reconsideration step, yet is again denied by the same nurse (no independent review of the RN’s initial denial analysis)
  • Claimant files mandatory appeal and is denied yet again

Ultimately, and after clearing all these hurdles, the claimant was able to sue Aetna.

The result: The federal judge overseeing the case remanded (sent it back) to Aetna for reconsideration, finding that the insurer’s denied appeal “completely lacks evidentiary support.” The court held that the claimant never received a fair review, given a doctor’s conclusion rendered “without any explanation or acknowledgment of the issues raised.”

A central takeaway from the matter is its spotlighting of the sometimes lengthy and challenging obstacles that a disability claimant can face.

Many individuals filing claims do ultimately persevere, though. That is especially true for those who timely consult with and rely upon the experience of proven disability attorneys committed to securing optimal outcomes in every client matter.