There is a lot of mixed information on long-term disability internal appeals. Some lawyers recommend skipping them and going straight to a lawsuit. While, others encourage you to try out an internal appeal to see what happens first.
Unfortunately, we can’t give you a clear answer on this either. However, this article will overview situations where it makes sense to do an internal appeal as well as scenarios where you should skip internal appeals for a lawsuit. We will also clarify the difference between an external and internal appeal.
This article is part of our Ultimate Guide to Long-term Disability.
What is a Long-Term Disability Internal Appeal?
When you apply for long-term disability benefits, your provider assigns an agent to review your claim and approve or deny it. If you get denied and request an internal appeal, the provider assigns a new agent to review the denial and decide whether to overturn it or let it stand.
We call this appeal “internal” because at this point it only involves you and the provider. “External” appeals involve an outside party, usually a judge or arbitrator.
Internal appeals are the first step in the appeals process, and most providers offer two or three rounds. But with some insurance plans, you may not need to go through all the rounds. If the first internal appeal fails, you can move right to the final appeal with the arbitrator or courts. Your HR department or union may not understand all the options that apply to you. We recommend booking a free legal consultation to get a straight answer on what options your plan allows.
When Should I do an Internal Appeal for a Long-Term Disability Claim?
Believe it or not, providers can and will admit when they made a mistake and approve your internal appeal. But you should only do an internal appeal if you have a chance to win. Your chances of success depend on your personal characteristics, claim evidence, and the provider’s reasons for denial.
Your personal characteristics include: your age, education, work history, pre-disability income, medical condition(s), symptoms, and temperament. If your provider missed a characteristic that validated your claim, you can point it out in the internal appeal.
Insurance companies sometimes deny claims due to your personal characteristics. For example, if you are over age 55, the insurance company may believe you want to use your disability benefits for “early retirement,” rather than for a valid disability claim. Or if you have an invisible medical condition (e.g. fibromyalgia, depression, etc.), then insurance companies may assume you are exaggerating due to a lack of objective testing.
However, more often the problem is a lack of information or gaps in your medical evidence. Common gaps in medical information can include a lack of discussion on the severity of your symptoms. Or the treatment done and planned. On appeal, you would need to have your doctors fill in these gaps by sending a letter or a medical report to the insurance company.
The provider’s reasons for denial can not only the include the stated reasons in the denial letter but also unnamed reasons. Often the unnamed reasons can relate to bias or stereotypes. Common examples include: you are too young to be disabled, you don’t like your current job, or that you want an early retirement. Unstated reasons for denial are harder to discover and dismiss.
When does it make sense to do an internal appeal?
You can win internal appeals in these kinds of situations:
- The provider denied your initial claim because they needed clarification from your doctor.
- You failed to provide requested information.
- You refused a particular treatment or appointment when you submitted the claim, but now you have.
- Your doctor provided incomplete or vague information.
- The provider’s doctor hasn’t evaluated you yet.
- The provider has no surveillance of your daily activities.
- The provider has yet to spend much money or time on your appeal.
If any of these reasons fit your situation, you should consider moving forward with an internal appeal.
Now let’s look at when you shouldn’t follow the process.
4 Reasons to Avoid Long-Term Disability Internal Appeals
Reason 1 – Your chances of success are slim to none
You should always go forward with an internal appeal if you have a reasonable chance of success. But what if you’re not sure what your odds are?
Consider whether any of these situations sound like yours:
- Your denial involves the two-year “change of definition” for occupation, where it switches from “own” (your last job) to “any” (whatever work you can find).
- The provider sent you to a medical examination, vocational assessment, or rehabilitation program, and you failed to follow through.
- Surveillance video shows you engaging in activities your disability should prevent.
- The provider has invested a lot of money on medical examinations, treatment, or video surveillance for your claim.
- Your denial cites technical reasons, like a pre-existing condition or late application.
- The provider blames your inability to work on your employer (a toxic work environment or insufficient accommodations for your disability.)
If any of the above situations sound like yours, don’t waste your time with internal appeals. You can still win, but you must let the provider know that you intend to pursue an external appeal. Some providers will even voluntarily reverse decisions before your case goes to court.
Reason 2 – Your provider’s well is deeper than yours
Have you heard of the Fabian strategy? This tactic defeats opponents by wearing them down over time rather than facing them directly. When used successfully, the Fabian strategy drains the opponent’s resources and morale without even entering a confrontation.
Multiple rounds of internal appeals can easily become a Fabian strategy, as this process drains your ability to fight for benefits. Think about it: a delay of several months or a year has much less effect on a provider’s resources than yours, especially if you can’t work.
After several months with no income, you may no longer have the money, time, or will to push through external appeals. Out of desperation, you’ll accept the provider’s settlement terms to get the ordeal over with rather than fighting for what you deserve.
Reason 3 – You may harm your disability claim
In most cases, moving forward with an internal appeal will not harm your long-term disability claim. However, if your claim involves any technical legal issues (toxic workplace or credibility problems), you can make a mess of things if you don’t carefully control your story and evidence.
For example, let’s say a “pre-existing condition” seems to exclude you from coverage under your policy. If you don’t understand what “pre-existing condition” means in your policy, you might accidentally create evidence that could hurt your case.
Or what if a toxic workplace contributed to your depression and anxiety? You and your doctor may overemphasize that factor in discussing your condition. Providers have successfully argued against paying benefits in these cases. Claiming that remedying your toxic workplace will cure your inability to work. Strangely enough, some claimants believe that focusing on the toxicity of their work environment helps. Please don’t make this mistake.
Reason 4 – You may run out of time to file a lawsuit
When the provider denies your claim or terminates your benefit payments, you have a limited amount of time to file a lawsuit –usually one or two years. Lawyers can make legal noise about when the “clock” begins. However, providers will always argue that it starts as soon as you receive the first denial letter.
One of my clients found himself stuck in internal appeals for over two years, making him miss the deadline. He eventually reached a settlement with the provider. However, the missed deadline forced him to accept a smaller amount than he deserved.
Don’t accept anyone’s assurances that you have plenty of time to file for an external appeal. As soon as you receive your denial, you can begin an internal or external appeal. However, always keep that ticking clock in mind.
In some cases, it makes sense to request an internal appeal. If you have just begun the claims process and have legitimate information that the provider did not consider, then an internal appeal has a good chance of success.
However, recognize when further internal appeals may not succeed – denials on technical grounds, the change of occupation definition, or the provider’s medical or video evidence that contradicts your claim.
Forcing yourself through internal appeals — with limited chances of success — will only drain your financial and emotional resources and get you nowhere. Your fatigue and frustration will have you making strategic mistakes and getting confused as the provider patiently waits for you to give up.
Do not let the process wear you down. Review your situation with the above points in mind, decide which direction you want to take, and move immediately.
If you’re unsure how your situation fits in these points, please call our disability support team toll-free at (888) 732-0470. Or, fill out the form below to book a free consultation.