erisa-appeal-guide">Long-Term Disability Denied? ERISA Appeal Guide

When a disabling condition prevents you from working and your long-term disability (LTD) insurer denies your claim, the financial and emotional impact is devastating. You are already coping with a serious medical condition, and now you face the loss of income you were counting on. LTD denials are unfortunately common — insurers deny a significant percentage of initial claims. But the appeal process, governed by ERISA for employer-sponsored plans, provides meaningful protections if you understand the rules and build a strong administrative record.

Why Long-Term Disability Gets Denied

Insurance companies deny LTD claims for several recurring reasons:

"You are not disabled under the plan definition." LTD policies define disability in specific terms that change over time. During the first 24 months (the "own-occupation" period), disability typically means you cannot perform the material duties of your own occupation. After 24 months, the definition usually shifts to "any-occupation" — meaning you must prove you cannot perform any occupation for which you are reasonably qualified by education, training, or experience. Many LTD claims are denied or terminated at the any-occupation transition.

"Insufficient objective medical evidence." LTD insurers frequently argue that your medical records do not contain sufficient objective evidence — diagnostic tests, imaging, clinical findings — to support your claimed level of disability. This is particularly common for conditions where symptoms are primarily self-reported, such as chronic pain, fibromyalgia, chronic fatigue syndrome, and mental health conditions.

"Surveillance contradicts your claim." LTD insurers routinely conduct physical surveillance on claimants — following you with cameras to document your activities. If the surveillance shows you engaging in activities the insurer believes are inconsistent with your claimed limitations (such as shopping, driving, or exercising), they may deny or terminate your claim.

"Independent Medical Examination (IME) contradicts your treating physicians." The insurer may send you to a physician of their choosing for an IME, or they may commission a "paper review" where a physician reviews your records without examining you. If the IME physician concludes that you can work, the insurer may rely on that opinion over your treating physicians' opinions.

"Pre-existing condition exclusion." Most LTD policies exclude disabilities caused by conditions that were diagnosed or treated within a look-back period (typically 3-12 months) before coverage began. Insurers may apply this exclusion broadly, including conditions you disclosed during enrollment.

Your Legal Rights

ERISA provides the primary legal framework for employer-sponsored LTD appeals:

ERISA Section 502(a)(1)(B) gives you the right to bring a civil action to recover benefits due under your plan. This is the statutory basis for filing a lawsuit if your appeal is denied.

29 CFR Section 2560.503-1 sets detailed requirements for ERISA claims procedures, including: written notice of denial with specific reasons, at least 180 days to file an appeal, the right to submit additional evidence on appeal, review by a person who was not involved in the initial denial, and a requirement that the reviewer consult with appropriate medical professionals.

The administrative record requirement. This is critical to understand: if your LTD appeal is denied and you file a lawsuit, the court will generally review only the evidence that was in the administrative record at the time of the final appeal decision. This means the appeal is your one opportunity to submit all supporting evidence — medical records, expert opinions, vocational assessments, and any other documentation. Evidence not submitted during the appeal may be excluded from court review.

Conflict of interest considerations. When your LTD insurer is both the entity that decides your claim and the entity that pays the benefits, there is an inherent conflict of interest. The Supreme Court recognized this in MetLife v. Glenn (2008), holding that courts must consider this structural conflict when reviewing denial decisions, though it is not automatically dispositive.

State law protections. While ERISA preempts most state laws for employer-sponsored plans, LTD policies purchased individually (not through an employer) are governed by state insurance law, which often provides stronger consumer protections, including the right to sue for bad faith and consequential damages.

How to Appeal Step by Step

Step 1: Review the denial letter and plan document with extreme care. The denial letter must identify the specific reasons for the denial, the plan provisions on which the denial is based, any additional information needed to perfect the claim, and your appeal rights. Obtain a complete copy of the plan document (Summary Plan Description and the actual policy), not just the SPD summary.

Step 2: Note the 180-day appeal deadline. Under ERISA, you have at least 180 days from the date of the denial notice to file your appeal. This is a hard deadline — missing it can waive your right to appeal and to sue. Start working on your appeal immediately.

Step 3: Identify every gap in your medical evidence and fill it. The administrative record you build during the appeal is everything. If the insurer says your medical evidence is insufficient, determine exactly what is missing: updated diagnostic testing, functional capacity evaluations (FCEs), neuropsychological testing, specialist evaluations, or attending physician statements. Obtain every piece of evidence you can before filing the appeal.

Step 4: Obtain a Functional Capacity Evaluation (FCE). An FCE is a comprehensive physical assessment performed by a certified evaluator that objectively measures your ability to perform work-related tasks: sitting, standing, walking, lifting, carrying, reaching, and gripping. FCE results are powerful evidence because they provide objective, measurable data about your functional limitations.

Step 5: Address the own-occupation vs. any-occupation definition. If your claim was denied or is approaching the any-occupation transition, you need a vocational assessment. A vocational expert can evaluate whether your functional limitations, combined with your age, education, and work experience, preclude you from performing any occupation — not just any job, but any occupation for which you are reasonably qualified.

Step 6: Submit a comprehensive appeal with all supporting evidence. Because of the administrative record requirement, treat the appeal as if it were your trial. Include everything: updated medical records, specialist reports, FCE results, vocational assessment, lay statements from family and colleagues about your functional limitations, and a detailed appeal letter that addresses each denial reason point by point.

What to Include in Your Appeal Letter

• The denial letter with each denial reason identified and addressed
• A complete copy of your updated medical records from all treating providers
• Functional Capacity Evaluation (FCE) results
• Attending physician statements from each treating doctor addressing your specific functional limitations
• Specialist evaluations relevant to your condition (neurological, orthopedic, psychiatric, etc.)
• A vocational assessment (for any-occupation denials) from a certified vocational expert
• Lay statements from family members, friends, and former colleagues describing your functional limitations as observed in daily life
• Any diagnostic test results: MRI, EMG/NCS, neuropsychological testing, lab work
• A response to any IME or paper review opinion, with your treating physicians' rebuttal
• A response to any surveillance evidence, explaining context and limitations
• Citation to ERISA Section 502, 29 CFR Section 2560.503-1, and the plan's specific disability definition
• The Social Security Administration disability determination (if applicable)

When to Escalate

Consult an ERISA attorney before filing your appeal. This is one of the few situations where legal consultation before the appeal is strongly recommended. Because of the administrative record requirement, mistakes made during the appeal cannot be corrected later in litigation. An experienced ERISA attorney can ensure you build the strongest possible record and avoid common pitfalls.

File a lawsuit under ERISA Section 502. If your appeal is denied, you have the right to file a civil action in federal court. The court will review the administrative record and determine whether the insurer's denial was arbitrary and capricious (for plans granting the insurer discretionary authority) or correct (de novo review for plans without discretionary authority). Time limits for filing vary, so consult an attorney promptly.

Department of Labor complaint. If the insurer failed to follow ERISA claims procedures — for example, by not providing required disclosures, missing response deadlines, or failing to consult appropriate medical professionals — file a complaint with the DOL's Employee Benefits Security Administration.

State insurance department complaint. For individually purchased LTD policies (not employer-sponsored), file a complaint with your state DOI. State-regulated policies are not subject to ERISA and may provide access to bad faith damages.

Social Security Disability Insurance (SSDI). If you have not already applied for SSDI, do so. An SSDI approval can significantly strengthen your LTD appeal because Social Security uses a rigorous evaluation process. Many LTD policies offset SSDI benefits dollar-for-dollar, but the approval itself is powerful evidence of disability.

Frequently Asked Questions

What is the difference between "own-occupation" and "any-occupation" disability? Own-occupation disability means you cannot perform the material duties of your specific job. Any-occupation disability means you cannot perform the duties of any occupation for which you are reasonably qualified by education, training, or experience. Most LTD policies start with an own-occupation definition (typically for the first 24 months) and then transition to any-occupation. Many claims are denied or terminated at this transition point because the any-occupation standard is harder to meet. However, "any occupation" does not mean "any job" — it means any occupation matching your qualifications, and the insurer must identify specific occupations they believe you can perform.

Do I need a lawyer for an LTD appeal? While you can file an LTD appeal on your own, the administrative record requirement makes legal representation particularly valuable. If your appeal is denied and you go to court, the judge will typically only consider evidence that was submitted during the appeal. An ERISA attorney can ensure you submit the right evidence in the right form. Many ERISA attorneys offer free consultations and work on contingency for LTD claims.

Can the insurer use surveillance against me? Yes. LTD insurers routinely conduct physical surveillance — following claimants with video cameras to document their activities. If surveillance shows you doing things the insurer believes contradict your claimed limitations, they will use it against you. However, surveillance is often misleading: a brief trip to the grocery store does not mean you can work full-time, and a good day does not mean every day is good. Your appeal should address surveillance evidence directly, providing context about what the surveillance did and did not capture.

What if I was denied at the any-occupation transition? This is a critical juncture. You need both medical evidence (showing your functional limitations) and vocational evidence (showing that your limitations preclude all occupations matching your qualifications). Hire a certified vocational expert to perform a vocational assessment, and ensure your physicians provide specific, detailed functional limitations — not just a statement that you "cannot work," but specific restrictions: how long you can sit, stand, walk, lift, concentrate, and interact with others.

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