If you appeal your insurer’s denial of your claim, you should have realistic expectations and not expect the insurer to conduct a fair or independent review. Nevertheless, there are circumstances where one should submit an appeal.
Although your insurer will likely assert in its denial letter that your appeal will be “independently” reviewed by people who were not involved in the initial denial, such an assertion is highly misleading. Although the insurance company employees who decide your appeal may have different names and titles and work in different rooms in the insurer’s office, they are all required to decide your claim in conformity with the same self-serving and unfair claims practices that caused your claim to be denied in the first place.
Although your insurer will be heavily predisposed to deny your appeal, if your case is governed by ERISA, it is almost always a good idea to submit an appeal within the 180 days allowed and include all information that would undermine the purported bases for the insurer’s denial. You are not submitting your appeal for the insurance company; you are submitting it for the federal judge who will ultimately be in a position to reverse the insurer’s denial. In assembling the materials for your appeal, you need to be sure to provide all the information and appropriate expert opinions that the judge will need to recognize the illogic and unfairness of the insurer’s denial.
If your claim is governed by California law, whether to appeal is a complex decision and depends on many factors, some of which may be unique to your case. You must always also consider whether you are facing the deadline of the statute of limitations and whether you will lose significant rights if you do not file suit promptly. Fortunately, under California law, the insurer has an ongoing duty of good faith and fair dealing — and has the duty to fairly consider new evidence in support of your claim even after it is sued.