If your initial claim for long-term disability insurance (LTD) benefits has been denied by your insurance company, don't give up. All LTD policies provide for at least one, and often two, levels of administrative appeals—and it's through the appeals process that many workers eventually receive their benefits.
Here are some things to keep in mind if you're planning to appeal a denial of long-term disability, including the steps you should take when you've been denied LTD benefits.
It might seem odd that the same insurance company that denied your disability claim could reverse that decision on appeal. But LTD appeals are often successful because they're evaluated by different claim units within the company. And the examiners in those units sometimes disagree with the initial decision.
If you have employer-provided LTD insurance, federal law requires you to "exhaust all administrative appeals" before filing a lawsuit against the insurance company in federal court. That means you need to complete the company's internal review process before suing them.
But even if you have an individual plan not governed by federal law, you should still exhaust all your administrative appeals. There's no sense in filing a lawsuit before you have to.
Some insurance companies seem to deny most initial LTD claims. And long-term disability denials are issued for a whole host of reasons. Some are legitimate, and others are excuses.
Some LTD denials are based on eligibility. Your long-term disability might be denied for any of the following reasons:
Sometimes the insurer doesn't believe you're disabled. If the insurance company isn't convinced you're disabled, your LTD benefits will be denied. Any of the following could lead to a denial:
The insurance company must inform you in writing if your claim for LTD benefits has been denied. Your denial letter will explain why your long-term disability claim was denied and how to file an appeal. You need to understand both parts to successfully appeal a long-term disability denial.
Why were your LTD benefits denied? Pay close attention to the exact reason you're given for the denial, as this can affect how you proceed with your appeal. For example, if you were denied because your condition "lacked objective documentation," it likely means the insurance company wanted to see more test results, like:
If that's the case, you'll want to include additional test results as part of your appeal.
How do you appeal the long-term disability denial? The long-term disability appeal process will vary somewhat depending on the insurer. But under federal law, the insurance company must give you at least 60 days to file an appeal, though many LTD policies allow for more time.
Your LTD denial letter will explain the requirements for filing your administrative appeals, including the deadlines. Pay close attention to these details. A missed deadline or improperly filed appeal can give your insurer a justifiable reason to deny your LTD claim.
When appealing a long-term disability denial, there are some things you can do that will help you win your claim and other things you should avoid doing. Here are some basic dos and don'ts:
The vast majority of employer-provided LTD policies are subject to a federal law known as ERISA, the Employee Retirement Income Security Act. Under ERISA, once you've exhausted your administrative appeals, the "record" in your case is closed. You won't be allowed to submit any new evidence.
Evidence limitations under ERISA. If you file a lawsuit against the insurance company in federal court, under ERISA, the judge can only consider the evidence that was in your claim file for the administrative appeals. So, it's critical that you "stack the administrative record" with as much favorable evidence as you can while the record is open.
What kind of additional evidence should you submit? First, you should make sure that your file already contains all your relevant medical records, including the following:
If anything is missing, you'll need to request it and send it to your insurance company for consideration.
Include a detailed statement from your doctor. You should obtain an opinion from your doctor on your physical or mental limitations. Be sure to ask your doctor to answer specific questions about your impairments and how they affect your daily activities.
It's not enough for your doctor to simply state that you're "disabled." An effective medical opinion will state how your limitations affect your ability to work. If your doctor isn't willing to help with your case, find a doctor who will support your LTD claim.
Get supporting statements from others. Third-party reports from friends and family members can also prove helpful. They should focus on first-hand observations of your limitations and not offer opinions about your medical issues or whether or not you're disabled.
For instance, if you need help getting in and out of the car and the shower, your spouse should include that detail in a letter to the insurance company.
Understand how your insurer defines disability. Not all LTD insurers define "disability" the same way. And your insurer's definition can make a big difference in your case.
Some policies define disability as an inability to perform any occupation—meaning you can't do any kind of work. Others will consider you disabled if you can't perform your previous work (your "own occupation").
Check your policy's summary plan description—or even better—the plan document itself, for specific information on how disability is defined in your plan.
The general rule is this: the earlier, the better. Insurance companies won't hesitate to use your unfamiliarity with the process against you. Having an experienced ERISA attorney on your side vastly improves your chances of successfully appealing a denial or termination of long-term disability benefits.
An experienced lawyer knows how to craft a persuasive appeal letter to the insurance company and what kind of medical evidence you need to submit. Your lawyer might also be more familiar with doctors and specialists in your area who can potentially help with your case.
Learn more about the advantages of hiring a long-term disability attorney for your appeal.
Updated February 9, 2023