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LTD Claimant’s Failure to Submit Timely Appeal Was Fatal to His Disability Insurance Claim

Attorney Victor PeñaAuthor: Attorney Victor Peña

In a recent Florida case not handled by our law firm a claimant’s untimely submission of his ERISA appeal proves fatal to his claim. The case was decided by the United States District Court in the Middle District of Florida and reminds us of the importance of properly submitting an appeal in ERISA governed cases.

Mr. Applegate had received benefits for 24 months for his inability to perform the material duties of his own occupation before receiving a denial letter from his employer’s group disability plan issued by Liberty Life Assurance Company of Boston. Like in many group disability policies, after receiving benefits for 24 months, Mr. Applegate would be considered disabled if he was unable to perform his own occupation or any occupation for which he was reasonably qualified. Liberty found Mr. Applegate was not disabled under the terms of the policy beyond the 24 month mark.

Pursuant to ERISA guidelines, a claimant must be given 180 days to submit an appeal following an initial denial of benefits. Mr. Applegate submitted his appeal within the required timeframe; however, the appeal denial letter set forth procedures for review of a second appeal option which Mr. Applegate had 60 days to submit. On the sixtieth day, Mr. Applegate faxed a letter to Liberty Life requesting an additional 10 days to submit evidence from a treating physician in support of the appeal.

The letter stated:

“This letter is in response to your denial letter dated November 5, 2015. The Letter provides that additional information pertinent to review may be submitted within 60 days of the denial letter. I would like to request [an] additional 10 days to submit additional evidence from Mr. Applegate’s treating physician, Richard Hood, M.D.”

Nine days later, Liberty Life denied the request stating:

“Mr. Applegate has failed to properly exhaust his administrative right of appeal. Therefore, Liberty is unable to accept or review any additional documentation with regard to his claim.”

Although the additional evidence from Dr. Hood was eventually submitted to Liberty, they refused to accept it or review it in conjunction with any appeal. Mr. Applegate filed a lawsuit against Liberty Life following receipt of Liberty’s decision to decline the request for an appeal.

Upon review, the court pointed out the errors in Mr. Applegate’s requests. The most important had to do with the absence of an actual request for a review. While insurance carriers may sometimes give additional time to submit more evidence in support of an appeal the actual appeal request must be submitted within the required timeframe. The court concluded that Mr. Applegate’s faxed letter was insufficient to initiate an administrative review because while it may have suggested a future intention to file a request for review or appeal upon Mr. Applegate’s receipt of additional evidence, the letter did not “facially purport to initiate or otherwise constitute the initiation of a review or appeal.”

The court found that Mr. Applegate failed to exhaust his administrative remedies and that there were no exceptional circumstances to excuse his failure to do so.

What we learn from this case?

The obvious points are you must submit your appeal timely and ERISA is very strict when it comes to these timeframes.

The other take away from this case is if you have to request more time do not wait until the day the appeal is due before simply asking for more time. If you find yourself running out of time to submit an appeal some insurance carriers may give more time but you should submit the request, in writing, well before the due date to allow time for the carrier to respond with a yes or no. Also, an appeal letter must specifically ask for an appeal to be opened. In other words, the request must be clear that it is intended to serve as an appeal and if you would like more time to submit additional information then additional time can be requested in the same letter. Whether more time will be provided is up to the carrier.

The approach will obviously always depend on the circumstances and time left to submit an appeal but the most important take away from this case should be that an experienced ERISA attorney should always be consulted in a timely fashion before submitting an appeal. Do not wait until the day before the appeal is due to contact an attorney.

If you need assistance with your disability insurance appeal or have questions regarding your disability insurance denial, please contact the law office of Attorneys Dell & Schaefer for a Free Consultation.



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