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My Insurance Company Denied My Disability Claim. What Do I Do?

If your claim has been denied, you have essentially two options. You can appeal or you can sue your insurer. It is possible that your insurer will wish to enter into a settlement or “buy-out” of your policy — but such an offer from your insurer is far more likely to come only after you have appealed or filed suit.

Whether to appeal or file suit without submitting an appeal depends on a great number of factors. The decision cannot be made without a thorough evaluation of the claim — including whether it is governed by the federal law, the Employee Retirement Income Security Act of 1974 (known as “ERISA”) as opposed to California law, the nature of the evidence you have already submitted to the insurer, and the content of the insurer’s denial.

It is possible that a claim that appears to be governed by ERISA may be governed by the much more favorable California law.

Should I Appeal The Denial Of My Claim Or Just File Suit?

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.

What Are The Deadlines For Appealing Or Filing Suit?

If your case is governed by ERISA, you have 180 days from your receipt of the insurer’s denial within which to submit an appeal. If your appeal is then denied, the period within which you may timely file suit can vary. Although insurers frequently state in policies governed by California law that the insured has 180 days to appeal, there is no such deadline under California law and, to that extent, the policy language advising of the 180 day deadline is misleading.

In ERISA cases, the deadline for filing a lawsuit can be a trap for the unwary. The insurance policy itself may set a deadline that is shorter than the statute of limitations set by California law (and adopted by ERISA) — a statute of limitations that is generally four years from the date of denial of your appeal.

If your case is governed by California law, you must file a lawsuit within two years of the denial or else you will lose the very important right to claim damages for bad faith — for the insurer’s unreasonable denial of your claim. If the two-year statute of limitations is missed, it is generally still possible to file suit to recover the policy benefits within four years from the denial. However, if you file after the two-year deadline, you will be generally be barred from recovering damages for emotional distress and also barred from recovering punitive damages to punish and deter the insurance company from engaging in the same or similar conduct in the future.

How Can A Lawyer Assist Me With Filing A Claim For An Event Covered Under My Insurance Policy?

When filing a claim, our San Francisco, CA insurance policy lawyer can be instrumental in ensuring that the process is handled efficiently and effectively. They will review your policy in detail to understand the coverage specifics and identify the full extent of benefits you’re entitled to. They’ll help compile all necessary documentation, from proof of loss to supporting evidence, and communicate on your behalf with the insurance company to mitigate the often-complex jargon and stipulations involved. 

Your lawyer will also advocate for your rights if the insurer disputes the claim, providing robust representation to challenge any unfair denials or underpayments. With their knowledge and experience, an insurance policy lawyer can navigate the legal and procedural nuances, maximizing your chances of a favorable outcome in the claim process.

How Does A Misdiagnosis Qualify For Legal Action?

A misdiagnosis can have a variety of negative effects on your health and well-being. If you have been the victim of a misdiagnosis, it is important to seek recourse for the physical and financial pain it has caused. A misdiagnosis becomes a legal matter when it leads to incorrect treatment, delayed treatment, or no treatment at all, resulting in harm or injury to the patient. 

To qualify for legal action, it must be proven that a competent doctor would not have made the same mistake under similar circumstances, and that the misdiagnosis caused direct harm. Our San Francisco, CA misdiagnosis lawyer can help establish the standard of care that was expected, demonstrate how the misdiagnosis deviated from that standard, and convey the extent of the damages that resulted.

What Should I Do If I’m Unable To Work Due To A Disability?

If you’re unable to work due to a disability, you may be entitled to disability benefits. The first step is to file a claim with the appropriate agency, such as the Social Security Administration for SSDI or SSI benefits. Our San Francisco, CA disability benefits lawyer can assist you with the application process, ensuring that all documentation is complete and filed correctly. 

A lawyer can also help gather medical evidence that supports your claim and advise you on how to best demonstrate the impact of your disability on your ability to work. Furthermore, they can represent you in any negotiations and hearings that may arise in order to fight for the full and fair amount of compensation that you deserve.

After A Disability Claim Denial, What Evidence Is Helpful In Supporting My Appeal?

If your initial claim has been denied, which is not uncommon, there is a structured appeals process that allows you to present new evidence. Strengthening your appeal typically involves submitting additional medical evidence that was not available during your initial application or that provides further clarification on your condition and its impact on your ability to work.

This new evidence can include updated medical records, new test results, or specialist evaluations that have occurred since the original submission. It’s also beneficial to include written opinions from your treating doctors, especially those that explain how your disability meets the SSA criteria. These medical professionals should be familiar with SSA’s “Listing of Impairments” and can provide insight into how your condition aligns with the listed criteria. Furthermore, non-medical evidence, such as witness statements from co-workers, family, or friends who can attest to the daily impact of your disability, can also be influential.

Our San Francisco, CA disability appeals lawyer will understand the local context and federal regulations, providing you with tailored advice on which types of evidence will carry the most weight in your appeal. They can help you navigate through the appeals process, from the Reconsideration stage to the Administrative Law Judge hearing, which is crucial for residents of California due to the variance in processing times and procedural nuances from one jurisdiction to another.

How Do I Know If I Have A Medical Malpractice Case?

Determining if you have a medical malpractice case involves assessing whether your healthcare provider breached the standard of care in treating you and whether this breach directly caused your injury and the losses you have received. You will need to show that the provider’s actions were not consistent with what a similarly skilled provider would have done and that this resulted in significant damages. 

Our San Francisco, CA medical malpractice lawyer can evaluate your case and advise you on the best path forward. If pursuing a claim of medical malpractice is the right step, they will assist you in gathering evidence, consulting with medical professionals, and navigating the legal process to seek compensation for your injuries.

Meet Bennett M. Cohen

San Francisco Personal Injury Attorney

Bennett M. Cohen brings over 30 years of litigation experience which includes representing plaintiffs against massive companies like the Shell Oil Company, Standard Insurance Company, and Metropolitan Life Insurance Company. Bennett M. Cohen brings an experienced and dynamic touch that separates himself from large law firms. He can oversee every aspect of your case, ensuring you receive specialized assistance.

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