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J.B. Asked: Can I Appeal a Disability Insurer's Medical Review?

On August 5, 2022, J.B. Asked:

“I have long COVID and I recently filed a claim for disability insurance benefits through my workplace disability policy. The insurance company relied on a clinician’s review of my medical records to deny my claim. The clinician is employed by the insurance company, they never examined me in-person, and they do not specialize in a field of medicine relevant to my long COVID symptoms. Can I appeal the insurance company’s decision?”

Answer:

Yes. The Employee Retirement Income Security Act of 1974 (ERISA) empowers employees to appeal adverse benefit determinations by workplace benefit plan administrators, including denials of disability insurance benefits by disability insurance plans. Insurance companies commonly rely on staff clinicians to review claimants’ medical records to deny their eligibility for benefits. However, these clinicians are often biased and work to advance the insurance plan’s interests by denying valid claims.

To overcome a denial of benefits, employees should pursue appeals according to their policy’s grievance and appeals process. When appealing an adverse benefit determination, employees are able to provide additional clinical evidence to support their claim. For their appeal to succeed, employees should work with their clinical care team to comprehensively document their disabling symptoms. Documentation from clinicians that specialize in areas of medicine relevant to long COVID symptoms is particularly helpful. For example, a long COVID patient who is experiencing disabling cardiovascular symptoms should try to work with a cardiologist to document their symptoms. Some common long COVID symptoms, such as brain fog and fatigue, are challenging to objectively document and present unique challenges. However, some supplemental documentation strategies may be helpful. For example, employees can keep a daily journal that describes how their long COVID symptoms manifest each day, how severe they are, and how limiting they are. Long COVID patients can review their journal entries with their doctor during their appointments to assist them as they articulate the patient’s symptoms in their medical record.

If the employee benefit plan continues to deny the employee’s claim for benefits, the employee can ultimately bring a lawsuit in federal court. In such a lawsuit, a court is able to intervene to reexamine the employee’s claim for benefits under the terms of the workplace benefit policy. If the court finds that the plan unfairly denied the employee’s claim, the court may compel the plan to award benefits to the claimant.

See our post, Long COVID Patients Bring ERISA Lawsuits to Secure Disability Benefits, to learn more.

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