How We Help
- Application for disability benefits from private or group plans
- Appeals of the denial of ERISA based long term disability claims
- Submissions to challenge the denial of individual disability insurance claims, pre-suit
- Litigation of ERISA and private disability claims in federal court and state court
- Monitoring active claims by submitting pertinent evidence to ensure their continuation
- We handle Long Term Care Cases
- Application for long term care coverage under private policies
- Filing internal appeals of denied Long Term Care claims and coverage
What is Needed to Prove Your Disability Claim
We help you by carefully assembling your medical records, and evaluating whether the medical record accurately charts your course toward disability. Did the doctor fail to record material objective information now essential to proving your disability? Are there records that contradict the progressive medical condition and its impact on you? We carefully scrutinize your records before submitting a claim, so the path for a successful submission becomes clear.
We help document how your medical condition prevents you from performing your job demands.
We analyze the proper timing of the claim. Sometimes there is a potential to file a partial disability claim under a disability contract. For instance some of our physician and dentist clients have already made changes in their medical or dental practice, taking a medical leave or reducing their surgical duties, justifying an earlier disability claim. We review each disability insurance contract to note the criteria needed to file a successful claim and then our Rafel team works with you to obtain, analyze and submit your claim to the insurance companies.
Disability insurance companies use formulas and databases to identify and classify claims. So the initial information you provide to the insurance company is critical. For if you are placed in one pathway which suggests a quick “fix” of your medical condition, the insurer will mark your file as a short duration and then you have an uphill battle to win over the insurance adjuster to expand the length of your claim.
What is Needed to Provide a Long Term Care Claim
Many insurance companies fail to honor the obligations required of them under their long term care policies. We analyze the long term care policies, outline the proofs necessary to collect from the treating doctors, coordinate the data, and provide it to the insurance company on behalf of our elderly clients and their families. We help you obtain the payments you deserve.
Authorizations- Must You Sign Them?
It is reasonable for an insurer to seek medical information about you, when investigating a claim. They do this by requiring you to sign a lengthy authorization, permitting the release of private, sensitive medical information. Often these authorizations are way too broad, permitting the insurer to obtain and then re-release to others your medical data, some of which may be totally unrelated to your claim. Insurers demand that you sign authorizations allowing them to obtain your personal financial data, and personal and business tax returns. Disability insurance companies request medical data from your physicians and perform an extensive sweep of your financial and medical past before deciding to pay a claim. We review authorizations carefully and redact sections that are not relevant to your claim.
Financial Information- Must I permit the insurer to obtain financial records, including banking or credit card data?
Insurance companies often send in a list of financial documents request that you provide as part of the submission of a claim. This is not to assist you in your claim, but really to see if there is another reason for you to be filing for disability. Reasons can be many. but perhaps your business was failing, you owed the federal government taxes, your disability benefit would exceed what you were earning while working. The bona fide reason to see income tax returns is to verify that you were actually working in your profession before disability struck. Your family’s financial status, otherwise, such as your investments in the stock market, other properties you own, or even what your spouse earns is irrelevant and an invasion of your privacy. We had a case where the insurer wrote to my client’s credit card company, seeking information about his account and in response, his credit card was frozen. We are very careful in determining what our clients should authorize the insurer access to with regard to financial data.
Appeals for ERISA claims
Disability Claims for Employees of Companies (ERISA)
People can often obtain group long term disability income benefits by opting in to a group plan provided by their employer. These will be regulated by “ERISA”, or the Employee Retirement Income Security Act of 1974. ERISA was enacted to provide certain protections for people with private health and pension plans, as well as employer-provided long-term and short-term disability insurance coverage. It regulates employer disability plans, outlining provisions for how claims should be processed, the timeline for processing them, and an individual's rights when a disability claim is denied.
When a claim is denied, ERISA requires that the employee contest the denial through what is called an “administrative appeal.” The appeal is furnished to the same insurance company who denied the claim, but they are required to have different employees review the denial than the employee who issued the initial decision.
Important First Step When You Receive a Denial of Short Term or Long Term Disability Benefits
There are steps to take to collect and assemble the necessary documents to file an administrative appeal. The denial letter you receive is often confusing. In some cases, the insurer provides a single page labeled "appeal" with the denial, baiting you to simply write a one-page appeal of the denial. This is a trap.
ERISA requires that you file an appeal within 180 days of the denial letter. Take the deadline seriously because if you fail to comply with the time guidelines, it may result in a waiver of your right to appeal and the decision will be final. Most claimants do not understand their rights when their claim is denied.
The first thing to do is to demand in writing a copy of your entire claim file, including all notes, records, surveillance tapes, company guidelines that were applicable to your short-term or long-term insurance claim used to decide your claim. You have a right to have a copy sent to you at no charge. We take care of this first step for potential clients who contact us regarding a denial of their claim.
The Rafel Successful ERISA Appeals Strategy
We step in immediately when retained by a claimant whose claim was denied. We obtain the entire claim file, review it carefully and plan with our client what evidence to gather and how to most effectively lodge an appeal of the wrongful denial. We first meet with you to listen to your story to be sure that you are heard and understood. You need us to really “get” what has happened to you, and why your claim is meritorious.
We bates stamp every page of your claim file and write up a chronology of everything that happened since your claim began. This is tedious process, taking a paralegal a week on average to prepare. Then we review the chronology carefully, often seeing key changes in the claim handling as the insurer prepared to deny the claim. We then strategize how best to collect the information necessary for the appeal battle.
This may involve witness statements, vocational reviews ormedical questionnaires we customize for the claimant's treating doctors to complete; the Rafel firm creatively orchestrates the collection of relevant evidence to prove the claim should be paid.
Attorney Rafel writes a custom appeal for every case she handles. This is similar to a court brief, laying out all of the important facts, telling the story of the case and weaving in all positive evidence to support the claim. She artfully challenges the basis for the insurer’s denial, calling them out and persuading the appeal department of the insurance company to question their own employee’s thoroughness and the correctness of the decision. There is no doubt that when the insurance company’s appeal department receives the Rafel appeal, they have to spend quite a bit of time studying it, and know that Rafel “means business”.
The insurance company then has 45 days to issue its decision on the appeal, or seek another 45 day extension. Unless the claim is approved during that time period, there is yet another mandatory step in the process of the appeal. Under the new ERISA regulations, (29 C.F.R. 2560.503-1(h)(4)(i) - Claims Procedure) the insurer is required to:
“provide the claimant, free of charge, with any new or additional evidence considered, relied upon, or generated by the plan, insurer, or other person making the benefit determination (or at the direction of the plan, insurer or such other person) in connection with the claim; such evidence must be provided as soon as possible and sufficiently in advance of the date on which the notice of adverse benefit determination on review is required to be provided under paragraph (i) of this section to give the claimant a reasonable opportunity to respond prior to that date”
We receive and review the new evidence provided by the insurer and often have to supplement our appeal with another comprehensive response to the new evidence which usually is medical consultant reviews or vocational analysis.