How to Appeal a Disability Insurance Claim?

If you are denied disability from your policy, or if your insurance company has notified you that it is discontinuing you disability benefit payments, you must appeal the denial.

YOU CANNOT TAKE YOUR CASE TO COURT UNLESS YOU HAVE COMPLETED THE ENTIRE APPEALS PROCESS WITH THE INSURANCE COMPANY.

Generally, individuals will only have one appeal of a disability denial. The appeal must be prepared very carefully since in federal court, and in some state courts, one is bound to the "administrative record," which the documentation is considered by the insurer or plan on appeal. If this is the case, a lost appeal that is litigated will be limited to only the documents that were submitted to the insurance company or plan and that the only consideration for the court will be whether the insurance company or plan made the right decision at the time. In these cases, subsequent medical information will not be considered.

It is crucial that you have your physicians involved to address the reasons for the insurance company’s denial. Typically the company has used an outside physician who has determined that you are no longer disabled. However, there are critics who believe that these outside physicians lean toward denying benefits and do not consider the entire medical file.

IMPORTANT: Any disability appeal must address BOTH the medical reasons AND the occupational reasons rose by the company for denying your disability. The physician must document the reasons for the disability and must do so while considering the employment requirements the insurance company has stated. The physician must state why you are disabled and why you cannot engage in the material duties of your occupation.


The medical supports for his position are ESSENTIAL. Just supplying the medical records is not the strongest means of appealing the denial. It may also be necessary to have an occupational expert provide an analysis of why you cannot engage in the occupational requirements of your policy.

IMPORTANT POINTS TO REMEMBER:

Following are some important points to remember:

1. Have Your Policy: It is crucial that you have a copy of your insurance policy. In addition, if you received your health insurance through your employer you should have received a yearly summary of benefits.
2. Keep Records: Make certain you have the name of any person to whom you speak at the insurance company and all correspondence Note the date and time of all calls and get the person’s ID number and the identifying number of the call.
3. Obtain the Denial Letter: Make certain you have your denial letter since companies often only notify the doctor. The letter is vital since it states the reason for the denial and the date which sets the clock running for all appeals.
4. File an Appeal: IMPORTANT: You should always appeal any denial. It is critical you take advantage of the appeal process since it may be the only chance you have of obtaining your benefits.

IMPORTANT: THERE ARE DEADLINES FOR FILING APPEALS AND CLAIMS IN COURT. FAILURE TO COMPLY WITH TIME DEADLINES MAY FORFEIT RIGHTS TO AN APPEAL OR TO PURSUE THE CASE IN COURT. IT IS IMPERATIVE TO UNDERSTAND AND COMPLY WITH ALL DEADLINES. YOU SHOULD CONSIDER CONSULTING AN ATTORNEY ABOUT THESE TIME FRAMES AND YOUR RIGHTS.