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LTD Lawsuit Dismissed Where Plaintiff Failed to Appeal Denied Claim Before Filing Suit

Group Long Term Disability Lawsuits Require An Appeal Before Suit is Filed in Court

If you have a disability claim under your employer’s group Long Term Disability (LTD) plan, you have to use the plan’s pre-suit appeal process before you can file a lawsuit.  What does this mean?  If the LTD insurance company handling the group claims denies your disability claim, you have to file an appeal with the insurance company within 180 days of the day your claim was denied.

This process of filing an appeal is called “exhausting administrative remedies.”  When you exhaust, that means you have appealed your denied LTD appeal claim.  You have to do this before you file a lawsuit against the LTD plan or the disability insurance company.

The U.S. Circuit Court of Appeals for the Eleventh Circuit – the federal appeals court that includes Alabama, Florida, and Georgia – has summed up the law that applies all across the U.S. as follows:  “The law is clear in this circuit that plaintiffs in ERISA actions must exhaust available administrative remedies before suing in federal court.” Counts v. Amer. Gen’l Life & Acc. Ins. Co., 111 F.3d 105, 108 (11th Cir. 1997).

What happens if you do not “exhaust administrative remedies?”

In a recent Alabama case, Tarif Qanadilo v. URS Corporation, the plaintiff’s attorney filed a lawsuit for several different types of claims against Aetna Life Insurance Company, the group disability insurance company running the LTD plan.  However, Qanadilo and his attorney never filed a pre-lawsuit appeal with Aetna.  Aetna moved to dismiss the lawsuit, arguing that ERISA (the federal law which governs group employee benefits law) required the employee to file that pre-suit appeal.  Because Qanadilo failed to file the required appeal, the court dismissed his lawsuit.

Just like the plaintiff in Qanadilo, if your LTD claim was denied, you must file the pre-lawsuit appeal or any lawsuit you file will be dismissed.

Why does the law require pre-lawsuit appeals?

Exhausting administrative remedies is required under ERISA, because courts do not conduct trials like you see on TV in ERISA cases.  Instead, cases are usually decided on written motions based on what is in your claim file.  Your employer’s group plan requires you to make a claim for disability insurance benefits.  If the LTD insurance company wants to deny your claim, it has to send you a letter stating the reasons why it is denying your claim.  But it does not end there.

The ERISA law also requires you to file an appeal to provide the evidence that you think explains why the the insurance company was wrong.  You have to submit all of the evidence that proves your claim.  The insurance company then has to investigate your appeal, develop any of its own evidence, and then write a final decision letter.  If your disability benefits are denied after the appeal, the idea is that a court reviewing that decision will have a complete set of documents showing the facts on both sides of the decision after the appeal is done.

The types of evidence you need in your pre-suit appeal.

You probably think submitting your medical records to the LTD insurance company is enough.  Unfortunately, that is rarely true.  The insurance company forms and your medical records should already be in your file if your claim is denied.  Some of the other types of proof of your disability that you should consider submitting include:

  • witness statements explaining how you are limited;
  • photos showing you in situations where you were limited;
  • Functional Capacity Evaluation (FCE) testing;
  • Vocational Expert reports;
  • any other evidence which proves why the insurance company was wrong.

Anything that you can think of can go into your claim file.  Hiring a creative attorney to help prove your disability claim can help.  Whether you have counsel or not, you must make sure that anything that could possibly prove your disability claim and prove that the LTD insurance company was wrong to deny your benefits.

CASE:  Tarif Qanadilo v. URS Corporation (Aetna Life Insurance Company), No. 5:16-cv-635, 2016 WL 5791501 (N.D. Ala. October 4, 2016).

If your group disability insurance claim was denied, call one of our experienced ERISA attorneys to schedule a free consultation at (866) 282-5260.

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