What to Do If Your Long-Term Disability Claim Is Denied
Receiving a denial of long-term disability benefits can be frightening, especially when a medical condition has already taken away your ability to earn your regular income. But a denial does not necessarily mean the process is over.
Long-term disability, or LTD, claims are governed by the terms of the applicable insurance policy or benefit plan. Many LTD plans provided through private-sector employers are also governed by a federal law called the Employee Retirement Income Security Act of 1974, better known as ERISA. Other disability policies may fall outside ERISA and be governed by different rules.
For Pennsylvania residents, understanding which rules apply to your claim is one of the most important first steps after receiving a denial.
1. Read the Denial Letter Carefully
Do not put the denial letter aside, even if the insurer’s reasoning seems confusing or unfair.
The letter should explain why your claim was denied and provide information about your appeal rights and applicable deadlines.
For an ERISA-governed disability plan, federal regulations require an adverse benefit determination to include specific information, including the reasons for the denial, reference to the plan provisions on which the decision is based, and information about the plan’s review procedures. Disability denial notices are also subject to additional requirements concerning the explanation of the decision.
Look closely for:
The specific reason or reasons for the denial
The definition of “disability” used by the policy
Medical evidence the insurer says is missing or insufficient
Any disagreement with your treating providers
Issues involving your job duties or ability to perform other work
The deadline for filing an appeal
Instructions explaining where and how the appeal must be submitted
The reason for the denial should help guide what evidence needs to be addressed in an appeal.
2. Determine Whether ERISA Applies to Your LTD Plan
This distinction matters because ERISA establishes specific federal procedures for claims and appeals.
Most private-sector employer benefit plans are subject to ERISA, and disability benefits can qualify as employee welfare benefits under the law. However, ERISA generally does not cover governmental plans or qualifying church plans, among other statutory exceptions.
An individually purchased disability insurance policy may also be treated differently from an employer-sponsored ERISA plan.
Do not assume that every Pennsylvania LTD claim follows the same appeal procedure. The policy, plan documents, employment arrangement, and applicable law all matter.
3. Pay Close Attention to the Appeal Deadline
Missing an appeal deadline can seriously affect your rights.
For an ERISA-governed disability plan, federal rules require the plan to provide a claimant with at least 180 days after receiving notice of an adverse benefit determination to file an appeal. A plan may provide a longer period, so the specific plan documents and denial letter should always be reviewed.
The same 180-day rule should not automatically be assumed for every non-ERISA disability insurance policy.
If you receive a denial, identify the applicable deadline as soon as possible rather than waiting until the appeal period is almost over.
4. Request the Claim File and Relevant Documents
If your LTD claim is governed by ERISA, you have important rights to information used in evaluating your claim.
Upon request, the plan must provide reasonable access to and copies of relevant documents, records, and other information relating to the claim free of charge. A claimant may also request information identifying medical or vocational experts whose advice was obtained by the plan in connection with the benefit determination.
These materials can help show:
What medical records were reviewed
Whether important records were missing
What medical opinions were obtained by the insurer
Whether vocational evidence was considered
How the insurer interpreted the policy
What evidence was relied upon in reaching the denial
Understanding exactly what the insurer considered can make it easier to address weaknesses in the original claim.
5. Review the Medical Evidence
Long-term disability claims often turn on more than a diagnosis.
The insurer will generally evaluate whether the medical evidence demonstrates that you satisfy the policy’s particular definition of disability.
That can make documentation of your functional limitations especially important.
Depending on the condition and the reason for the denial, relevant evidence might include:
Treatment records
Diagnostic testing
Physician reports
Specialist evaluations
Documentation of medication side effects
Physical or mental functional limitations
Restrictions involving sitting, standing, walking, lifting, concentration, memory, or stamina
Information explaining why your condition prevents you from performing your occupational duties
The exact evidence needed will depend on the terms of the LTD plan or policy and the insurer’s stated reasons for denying the claim.
6. Make Sure Your Actual Job Duties Are Accurately Described
An insurer may evaluate whether your medical limitations prevent you from performing your occupation or, depending on the policy and stage of the claim, another category of work.
That makes an accurate description of your work important.
A job title alone may not fully explain what you actually did each day.
For example, two employees with similar titles may have very different responsibilities involving:
Sitting or standing
Lifting
Travel
Fine motor skills
Concentration
Decision-making
Customer interaction
Deadlines
Computer use
Physical activity
If the insurer’s understanding of your occupation is incomplete or inaccurate, that issue may need to be addressed as part of the appeal.
7. Submit a Complete Appeal
An appeal should generally do more than simply tell the insurer that you disagree.
For ERISA-governed claims, federal regulations permit claimants to submit written comments, documents, records, and other information related to the claim. The plan’s review must take the submitted information into account even if it was not considered during the initial determination.
The U.S. Department of Labor specifically advises claimants to include all information related to their claim, particularly additional evidence they want the plan to consider, before the appeal deadline.
Depending on the circumstances, an appeal might address:
Errors in the insurer’s interpretation of the medical records
Missing medical documentation
Additional physician opinions
Functional capacity evidence
Vocational evidence
Errors concerning job requirements
Policy provisions the insurer may have misapplied
Other factual or medical issues identified in the denial
A detailed appeal can be especially important because the administrative appeal process may significantly affect what happens if the dispute later proceeds to litigation.
8. Keep Copies of Everything
Keep a complete record of communications relating to your claim.
That includes:
The original application
The insurance policy or plan documents
The denial letter
Medical records
Physician statements
Forms submitted to the insurer
Appeal documents
Emails and letters
Fax confirmations
Certified-mail receipts or other delivery confirmations
Notes regarding conversations with the insurer
When deadlines matter, being able to document what was submitted and when it was received can be important.
9. Know What Happens After an ERISA Appeal
For ERISA disability claims, the plan generally must decide an appeal within 45 days, although an extension of up to an additional 45 days may be permitted when special circumstances require additional time and proper notice is provided.
If an ERISA claim remains denied after the required administrative process, ERISA provides a right to bring a civil action in appropriate circumstances. The final adverse benefit determination must also provide information concerning the claimant’s right to bring an action and applicable contractual limitations periods.
The rules for a non-ERISA policy can be different, which is another reason identifying the type of LTD coverage is important.
Pennsylvania Residents Should Know About the Pennsylvania Insurance Department
Pennsylvania residents with questions or complaints involving an insurance company can contact the Pennsylvania Insurance Department’s Bureau of Consumer Services. The Department maintains an online Consumer Services Portal where consumers can submit insurance-related questions or complaints and supporting documents.
However, Pennsylvania’s separate independent external review program is primarily a process for certain health insurance claim denials. It should not be confused with the appeal procedures that apply to a long-term disability income claim.
If you are facing an LTD denial, you should still follow the deadlines and appeal procedures applicable to your particular disability plan or policy.
Do Not Assume a Denial Is the End of Your Claim
Long-term disability insurers make decisions based on policy language, medical information, occupational evidence, and other documentation. A denial may sometimes result from missing evidence, disagreement about your medical restrictions, differing interpretations of your occupation, or disputes over the terms of the policy.
The appeal process provides an opportunity to address those issues—but deadlines can be strict, and the rules can become especially complicated when ERISA applies.
Long-Term Disability Claim Denied in Pennsylvania?
If your long-term disability benefits have been denied or terminated, Banks Law can help you understand the reason for the decision, determine what rules apply to your claim, and evaluate your options for challenging the denial.
Banks Law represents disabled individuals in Philadelphia and throughout Pennsylvania who are dealing with insurance companies and complicated disability-benefit systems.
Contact Banks Law to discuss your long-term disability claim and the next steps available to you.
This article provides general information and is not legal advice. Long-term disability policies and benefit plans vary, and the deadlines, procedures, and legal rights applicable to a particular claim depend on the specific policy, plan, and circumstances.