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Do I Have to Send a Pre-Suit Appeal in My Group Disability Insurance Claims or Can I Just Sue Them?

Tucker Law Group
March 29, 2016

Your disability insurance company just sent you a letter denying or terminating your Long Term Disability (LTD) insurance benefits.  You are so mad you could spit nails, and you cannot believe what you are reading.  When you get to the end of their letter, they tell you that you may file an appeal within 180 days, and they explain that you appeal the denial….right back to them!  That is right, the same insurance company that just said you were not disabled is giving you the chance to appeal their decision, and they get to decide if they were wrong?  Seems like a waste of time, doesn’t it?  You are wondering, why would I do the appeal?

If you have group disability coverage through your employer, the answer is simple.  You must file the appeal, because the law makes you do it.  And if you do not send them an appeal, you will never legally be allowed to win a lawsuit.

Why is this?  The U.S. Department of Labor has regulations that apply to group disability plans offered through private employers.  Those regulations spells out a whole series of procedures and time frames that are designed to give employees a full and fair review when they file a claim for disability benefits. The “full and fair review” is required by 29 U.S.C. Sec. 1133, one of the statutes that make up the Employee Retirement Income Security Act – ERISA.

ERISA is the the federal law that regulates employer provided insurance and pension plans.  One of the Department of Labor’s regulation, 29 C.F.R. Sec. 2560-503-1, requires disability plan administrators to decide claims within a certain time.  It also requires plan administrators to give employees 180 days to file an appeal if their claim is denied.  This appeal is mandatory for the employee and the ERISA plan administrator.  You have to file the appeal and they have to decide it.  Theoretically, the idea is to give the ERISA administrator the chance to fix any errors they made before getting a court involved by giving you the chance to send them anything they may not have seen or send in argument explaining why they were wrong.

They other key aspect of this is that you must get in all of your evidence during the appeal.  That means any evidence you would ever want a federal judge to look at if you have to file a lawsuit.  The reason for this is that you do not get to introduce doctor’s reports or their testimony in court if you did not send them to the administrator when you made your claim or when you filed the mandatory appeal.  Similarly, you do not get to offer the opinions of vocational experts, functional capacity experts, or even the testimony of lay (non-expert) witnesses talking about what they have seen that makes you disabled if you have not sent those in during the claim or during the appeal.  For this reason, having an attorney handle the mandatory appeal is crucial.

You must file the appeal within 180 days, and you must fully develop all of the evidence you would ever want a court to see in your case during the appeal.  Too many people do not do this.  If you are one of them and you do not appeal, you claim will be dead on arrival at the courthouse.  It will get dismissed by a judge.  If you sent in a simple letter saying you appeal without offering powerful evidence, your case, it likely will not make it out of the starting blocks either. Do not make those mistakes.  Be sure to appeal, and when you do, hit the disability insurance adjuster with all guns blazing.

If your Group / ERISA disability insurance claim was denied, call John V. Tucker at (866) 233-5044 or send Tucker Law Group an online inquiry using our Online Contact Page.  Mr. Tucker represents people just like you in ERISA disability claims and lawsuits all over the U.S.A.