By law, when an insurance company denies all or part of your Long Term Disability (“LTD”) or Life insurance claim and gives you the right to appeal their decision, you also have a right to request and receive, free of charge, a copy of all documents the insurance company produced or considered in the evaluation of your claim. This group of documents is commonly referred to as the “Claim File.” This includes all the correspondence, internal notes and memos, medical records, reports by outside vendors (surveillance reports and videos, reports from doctors they had you see or sent your records to for a peer review, vocational reviewers, etc.), and copies of your Plan and/or Policy.
Seems simple enough, and certainly that is the type of stuff you’d want to know before appealing their decision. So why then, do so many people appeal without requesting and reviewing their Claim File?
The main reason people fail to request their Claim File when their insurance claim is denied is because they don’t know that they can, even though insurers are required to notify you of this right within the denial letter. This is because insurers (not-so) cleverly try to hide your right to receive this information by burying it within the denial letter, or by phrasing it in a very inconspicuous manner. This is assuming they even mention it at all, as we have seen numerous denial letters that make no mention of your right to this information. Some examples:
“You may also ask for copies of documents relevant to your claim, and we will send them to you free of charge.” (Okay, but this hardly puts you on notice of the scope of the documents they have to send to you.)
“You are entitled to receive upon request, sufficient information to make a decision about filing this appeal.” (This one’s even worse. It doesn’t say it’s free of charge, and “sufficient information to make a decision about filing this appeal” is a gross understatement of what they are supposed to send you.)
“Upon request, [insurance company] will provide you with a copy of the documents, records, or other information we have that are relevant to your claim and identify any medical or vocational expert(s) whose advice was obtained in connection with your claim.” (Wow! A semi-clear statement of what they are required to send you. It doesn’t say free of charge, but it’s certainly the best of the bunch.)
Perhaps the most alarming thing we’ve discovered over the years though is that not only do people regularly fail to request their Claim File, but even when they do people just aren’t carefully reviewing the contents of the file before they submit their appeal. Oftentimes, a simple review of these documents can provide you with a road-map for how to attack the insurance company’s denial, and in some cases you can find information that definitively proves that the insurance company is just plain wrong.
Take a recent life insurance claim denial we handled, where the insurer denied a six-figure claim arguing that the deceased’s insurance was not in force at the time of his passing. They offered two main reasons which seemed air-tight on the surface, and our client’s case was rejected by multiple law firms. After finding Kantor & Kantor, we reviewed what little information our client had and we identified some issues with the insurance company's denial that just didn’t make sense.
Our first step after taking on the case – you guessed it – request the Claim File from the insurance company. A close inspection of the documents (300 pages or so) revealed that the first basis for denial was not only lacking in support, but the evidence in the file actually showed that the insurance company was dead wrong in the position they had taken. The second basis for denial, which seemed black-and-white according to the denial letter and was the reason every other law firm passed on the case, actually pointed to some negligence on the part of both the insurance company and the employer who provided the life insurance coverage to the deceased.
To make a long story short, we communicated all of our arguments to the insurer, cited to documents in THEIR file, and demanded they pay benefits. After speaking with the employer, the insurance company agreed to pay the full value of the claim, essentially admitting that both they and the employer had improperly denied benefits.
Now, it’s not always going to work out that way. There won’t always be a “smoking gun” in the Claim File for you to discover that will give the insurer no choice but to overturn their denial. But I guarantee you that if your LTD or life insurance claim is denied and you request and carefully review your Claim File, you will often discover multiple inaccuracies, inconsistencies, and omissions that will greatly help you in the crafting of your appeal.
So when your insurance claim is denied, make sure the first thing you do is to request, in writing (traceable forms are best; i.e. certified mail or fax), a copy of your Claim File. Then look it over carefully, especially if you plan on doing the appeal on your own. Look closely at what your doctors had to say, compare that to what their doctors said, look for missing information that you know should be there, and then supplement the Claim File with additional missing information that supports your claim. And if that proves to be too cumbersome for you, the attorneys at Kantor & Kantor are always willing to review your case, free of charge, to see if we’re interested in handling the appeal for you.