erisa-long-term-disability-claim-denied-how-to-appeal">ERISA Long-Term Disability Claim Denied: How to Appeal

Long-term disability (LTD) insurance replaces a portion of your income when illness or injury prevents you from working. Most group LTD policies offered through employers are governed by ERISA. When an LTD insurer denies your claim — or terminates benefits you were already receiving — the stakes are high and the process is legally complex. This guide explains your rights and how to build the strongest possible appeal.

How ERISA Governs LTD Claims

Group LTD policies sold through employers are ERISA plans. This means:

• You must generally exhaust the plan's internal appeal process before filing suit
• Federal courts review the insurer's decision, often deferentially if the plan grants the insurer discretion
• State insurance laws and state bad faith claims are largely preempted
• Damages are generally limited to the benefits owed (no punitive damages under ERISA, though interest may be available)
• The claim file built during the internal appeal process becomes the evidentiary record for any subsequent lawsuit

This last point is critical: courts reviewing ERISA cases typically do not consider evidence that was not submitted during the internal appeal. Build your record completely before exhausting internal remedies.

Why LTD Claims Are Denied

Failure to meet the definition of disability: Most LTD policies have two definitions:

• Own Occupation: You cannot perform the duties of your specific occupation
• Any Occupation: You cannot perform any occupation for which you are reasonably qualified based on education, training, and experience

Policies often switch from "own occupation" to "any occupation" after 24 months. Denials frequently occur at this transition.

Lack of objective medical evidence: Insurers demand objective findings — imaging, test results, functional capacity evaluations — and may discount symptoms that are harder to measure, such as chronic pain, fatigue, or cognitive impairment.

Surveillance and social media monitoring: Insurers routinely conduct surveillance and monitor social media. Activity seen as inconsistent with the claimed disability is used to justify denial.

Paper review by non-examining physicians: Insurers hire physicians who review records without examining you and conclude you are not disabled. Courts have criticized this practice, but it remains common.

Failure to complete forms or comply with requirements: Missing a medical authorization, failing to see approved physicians, or not completing attending physician statements can result in denial.

Pre-existing condition exclusions: Many LTD policies exclude disabilities from conditions that existed before coverage began.

Mental health or substance use limitations: Many LTD policies limit mental health and substance use disorder claims to 24 months of benefits.

The ERISA LTD Appeal Process

Critical Deadlines

• To file an internal appeal: At least 180 days from the denial notice (plans may give more)
• Plan's decision deadline: 45 days for disability appeals (extendable by 45 days with notice, up to 90 days total)

For plans with only one level of internal appeal, you must exhaust that one appeal before suing.

Building Your Appeal: What to Include

Comprehensive medical records: Submit all records from all treating providers for the relevant period. Do not rely on the insurer to gather records — they may selectively use what supports their decision.

Treating physician statements: Ask your doctors to write detailed statements explaining:

• Your specific diagnoses
• How your conditions limit your functional capacity
• Why you cannot perform the material duties of your occupation (or any occupation)
• Their clinical basis for these conclusions (examination findings, test results, clinical history)

Functional Capacity Evaluation (FCE): A formal FCE performed by a licensed occupational therapist or physical therapist provides objective functional limitations data and can be highly persuasive.

Neuropsychological testing: For cognitive impairment claims (brain fog, TBI, psychiatric conditions), neuropsychological testing provides objective data.

Vocational expert opinion: A vocational rehabilitation expert can analyze your specific occupation's demands, your limitations, and whether you are capable of performing that job or any job.

Challenge the insurer's reviewers: If the insurer used a paper review physician, research that physician's history — consulting doctors who primarily work for insurers have sometimes been criticized in court for bias. Request the physician's qualifications, credentials, and any information about their other work for the insurer.

Address every denial reason: Go point-by-point through the denial letter and respond to each reason with evidence and argument.

Submitting the Appeal

Submit by certified mail with return receipt requested. Keep copies of everything. Note the date submitted relative to the deadline.

After the Appeal: ERISA Litigation

If the appeal is denied, you can file suit in federal district court under ERISA § 502(a)(1)(B). Key litigation considerations:

Standard of review: Courts generally review discretionary LTD decisions under the "abuse of discretion" standard, meaning the insurer wins unless the court finds the decision was unreasonable. Some courts apply de novo review if the plan does not grant clear discretionary authority, or apply a "sliding scale" giving less deference when the insurer has a conflict of interest (since the insurer both evaluates claims and pays them).

Conflict of interest: The U.S. Supreme Court held in MetLife Insurance Co. v. Glenn (2008) that an insurer's dual role — evaluating and paying claims — creates a conflict of interest that courts must weigh when reviewing the decision.

Statute of limitations: ERISA has no uniform limitations period. Check your policy's contractual limitations clause. Many policies require suit within 3 years of the date proof of loss is due.

Consult an ERISA attorney: LTD litigation is highly specialized. Many ERISA attorneys offer free initial consultations and work on contingency.

Fight Back With ClaimBack

An LTD denial during a period of serious illness or injury is devastating. ClaimBack helps you understand your rights, organize your medical evidence, and build a strong internal appeal that protects your rights and positions you for success at every subsequent level.

Start your appeal with ClaimBack

Related Reading

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity in Insurance?
• Internal vs. External Insurance Appeals Explained