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Short-term disability insurance covers specific qualifying disabilities, including pregnancy. It serves to substitute a portion of your income until you recover and can resume work. In case of a denial, you'll likely appeal by submitting an appeal letter with supporting documents. Your letter should concisely explain why you meet the disability criteria outlined in your plan.
Steps to Follow
Developing Your Argument
Review the denial letter. Your insurer will provide a letter detailing the reasons for denying your short-term disability benefits. Carefully analyze this letter to understand the grounds for denial, which may include inadequate information or non-coverage of your disability under the policy.
Understand the Appeals Process. Your denial letter should outline the procedure for appealing and specify any deadlines. Take note of this information and mark deadlines on your calendar to ensure compliance.
- If this information is absent, promptly contact the insurance company for clarification.
Obtain Necessary Documentation. If you receive short-term disability benefits through your employer, you're entitled to request your claim file, summary plan description, and policy. The plan administrator must furnish these documents within 30 days.
- Submit a written request to the plan administrator, either your employer or the insurance company.
- Send the letter via certified mail with return receipt requested and retain the receipt for your records.
Compile Supporting Evidence. If your claim was denied due to insufficient information, gather relevant supporting documentation to include with your appeal letter. Examples may include:
- Medical records from your physician
- Expert opinions from medical professionals
- Written statements from colleagues or supervisors regarding the impact of your injury
- Additional records, such as police reports for accident-related injuries
Consider Legal Assistance. If you're unsure how to proceed with the appeal process, consulting with a lawyer may be beneficial. However, it's essential to weigh the potential costs against the benefits of obtaining short-term disability benefits.
- Individuals with low income may qualify for legal aid services, offering low-cost or free legal assistance. Visit http://www.lsc.gov for more information.
- Some employee assistance programs offer complimentary consultations with attorneys. Review your plan details for eligibility.
- Seeking brief legal advice from a lawyer can be cost-effective. Many lawyers offer half-hour consultations at a reduced rate. Contact your local or state bar association for lawyer referrals.
Submitting Your Appeal Letter
Structure the Letter. Arrange the letter following the format of a typical business correspondence. Maintain double spacing and opt for a legible font style, such as Times New Roman, size 12.
Provide Essential Details. Ensure the insurer can identify you and understand the purpose of your appeal. Include the following information:
- Your full name
- Policy number or identification details
- Reason for the claim denial
- Brief overview of your disability
State Your Case. Clearly articulate why the insurer should reconsider your claim. Reference your supporting documentation and argue how it demonstrates your eligibility for benefits.
- For instance, you might state, “As evidenced by the enclosed medical records, I sustained a fracture on August 15, 2016. Due to the physical demands of my job, which involve lifting objects above shoulder height, I have been unable to fulfill my duties since the incident. The accompanying statements from colleagues detail the impact of my injury on my ability to work efficiently. As such, I respectfully request approval of my application for short-term disability benefits.”
Include Supporting Documents. Prepare duplicates of all relevant paperwork, including medical records and coworker testimonials. Retain the originals for your records and refrain from sending them with the appeal.
Submit the Appeal. Retain a copy of the appeal letter for your records before dispatching it via certified mail with a return receipt request to the address specified by the insurer. Retain the mailing receipt for documentation purposes.
Await a Response. Expect the insurance company to assess your appeal letter and accompanying documents. Anticipate receiving a written response.
- Explore Further Appeals: The correspondence may outline additional appeal options and procedures. If your short-term disability coverage is provided through your employer, you can pursue further appeals. Initially, you may appeal to an administrative judge, with the potential for subsequent litigation in federal court.
