When a denied claim comes through it can feel like the end of the road. But is it?
Getting denied for Long-Term Disability (LTD) benefits can feel like a dead end. Many claims are denied on the first attempt, often due to missing documentation, policy misunderstandings, or procedural missteps. But the good news is that a strong, well-prepared appeal can turn things around. If your LTD claim has been denied, understanding why, gathering strong evidence, and following a strategic appeal process are critical to securing the benefits you deserve. This guide will help you navigate the appeals process and increase your chances of success.
Understanding Why LTD Claims Get Denied
Before you can appeal, you need to know the reason for your denial. Insurance companies are required to provide a written explanation outlining why your claim was rejected. Common reasons include lack of sufficient medical evidence, failure to meet the policy’s definition of disability, missed deadlines or procedural errors, discrepancies in medical documentation, and surveillance evidence suggesting the claimant is not as disabled as claimed.
Some denials are based on the insurer’s interpretation of whether a claimant has transferable skills to perform another occupation. For example, a surgeon who can no longer operate due to an injury may be told they can teach in a clinical setting, even if they lack the necessary experience. Similarly, an engineer who can no longer conduct fieldwork may be denied benefits because the insurer claims they can still perform other types of engineering work.
These determinations often fail to consider the practical realities of a person’s career history and credentials. Understanding these challenges allows claimants to challenge the insurer’s interpretation and build a case that accurately reflects their limitations.
Knowing Your Rights Under ERISA
If your LTD policy is employer-sponsored, it likely falls under the Employee Retirement Income Security Act (ERISA), which has strict rules about the appeal process. Under ERISA, you have 180 days to file an appeal after receiving a denial. The appeal process is administrative, meaning you cannot introduce new evidence in court later if it wasn’t submitted during the appeal.
The insurer must decide on your appeal within 45 to 90 days of submission. The statute of limitations is critical, as missing deadlines can bar you from making a claim. Unlike personal injury or other legal cases, LTD appeals falling under ERISA do not include oral depositions or jury trials. The decision is based entirely on the existing administrative record, meaning it is essential to submit as much evidence as possible during the appeal.
If the insurance company denies the appeal, a lawsuit may be filed for breach of contract for wrongful denial of benefits. In court, both sides may file cross motions for summary judgment, where the claimant argues that the insurer misinterpreted the policy and abused its discretion. If the administrative record is weak, the chances of success in court decrease significantly. Once a case reaches litigation, there is no opportunity to introduce new medical records or evidence that was not included in the appeal. This makes it critical to build a strong record before the lawsuit stage.
Steps to Building a Strong Appeal
The first step in building a strong appeal is strengthening medical evidence. This means obtaining updated medical records, treatment plans, and specialist evaluations. It is important to address any gaps or inconsistencies noted in the denial letter and to include both objective evidence, such as imaging and test results, and subjective evidence, such as doctor’s notes and patient-reported symptoms.
Statements from caregivers, family members, or others who can attest to the claimant’s daily limitations can also be useful. In cases involving mental health conditions, law enforcement reports or first responder statements may provide additional context. Documentation on prescription drug side effects, particularly when sourced directly from the manufacturer, can support claims of functional impairment. Medical literature and expert citations can also strengthen an appeal by providing a broader understanding of a condition’s long-term effects.
In addition to medical records, expert opinions play a critical role. Treating physicians should provide detailed reports explaining why the claimant cannot work. If necessary, evaluations from specialists should be included to reinforce the claim. Physicians should be asked to clearly link symptoms to functional limitations, as insurers frequently deny claims based on insufficient evidence of work-related restrictions.
Consistency across medical opinions is key, as conflicting reports can harm the case. A common issue arises when doctors inadvertently check off boxes on a form that contradict the claimant’s stated limitations. If a physician’s evaluation is incomplete or incorrect, it can be used against the claimant, which is why careful review and coordination with healthcare providers are essential.
Beyond documentation, it is important to address how the disability affects daily life and job performance. Statements from coworkers, supervisors, or vocational experts can provide valuable evidence. If the insurer has used surveillance footage to justify a denial, the claimant should clarify any misleading or out-of-context evidence. Misinterpretations of medical records or symptom severity should also be corrected with expert support.
Writing a Persuasive Appeal Letter
A well-structured appeal letter should clearly outline the claimant’s case and address each reason for denial in a concise, factual manner. The letter should provide a point-by-point rebuttal of the insurer’s rationale, supported by relevant medical and vocational evidence. It should include an overview of the claimant’s medical condition, an explanation of how it prevents them from working, and a request for a full and fair review under ERISA. This becomes a key exhibit if the case moves to litigation, making it essential to present a compelling argument.
The Role of Legal Representation in Appeals
While it is possible to file an appeal independently, working with an LTD attorney significantly improves the chances of success. An experienced attorney can analyze the denial letter and policy language, gather and present medical and vocational evidence effectively, ensure compliance with ERISA deadlines and procedural rules, draft a compelling appeal letter tailored to the insurer’s specific objections, and negotiate with the insurer. Attorneys also act as a buffer between the claimant and the insurance company, preventing unnecessary stress and allowing the claimant to focus on their health. Insurers often rely on claimants’ lack of legal knowledge to uphold denials, so having an experienced advocate is crucial.
What Happens After You File the Appeal?
Once the appeal is submitted, the insurer will review the case and may request additional information or schedule an independent medical exam (IME). A decision is typically made within 45 to 90 days. There are three possible outcomes. The first is full approval, in which benefits are reinstated, often retroactively. The second is partial approval, where benefits may be approved for a limited period. The third is denial, in which the claimant may consider filing a lawsuit.
Tips to Avoid Future Denials
To prevent future denials, claimants should stay compliant with treatment plans and regularly update their medical records. It is important to respond promptly to insurer requests and keep thorough documentation of all communications. Periodically reviewing the policy helps claimants stay aware of ongoing requirements and ensures they continue to meet eligibility criteria.
Conclusion
Appealing a denied LTD claim is not easy, but with the right strategy and thorough documentation, many denials can be overturned. By understanding the reasons behind the denial, gathering strong evidence, and submitting a well-structured appeal, claimants can improve their chances of success. Given the complexity of LTD claims and the legal nuances involved in ERISA cases, consulting with an experienced LTD attorney provides valuable guidance and support throughout the appeal process.