Long-Term Disability Denials

Understanding LTD Insurance

Long-term disability (LTD) insurance replaces a portion of your income (typically 50-70%) when you cannot work due to illness or injury. These policies kick in after short-term disability benefits expire, usually after 90-180 days of disability.

LTD policies come in two main forms:

• Employer-Sponsored (Group) Plans: Provided through your employer, often governed by ERISA (Employee Retirement Income Security Act)
• Individual (Private) Policies: Purchased directly from an insurer, governed by state insurance law

Common Reasons for LTD Denials

Insurance companies deny LTD claims for various reasons, some legitimate but many questionable. Understanding these tactics helps you prepare a stronger claim or appeal.

1. "Insufficient Medical Evidence"

The most common denial reason. Insurers claim your medical records do not adequately support your disability, even when multiple doctors say you cannot work. They often:

• Cherry-pick records that minimize your condition
• Ignore treating physician opinions in favor of paper reviewers
• Claim objective testing does not support subjective complaints
• Require specific tests that are not medically appropriate for your condition

2. Surveillance and Social Media

Insurers hire private investigators to conduct surveillance and scour your social media. They use cherry-picked footage to argue you are not as disabled as claimed, often taking activities out of context.

3. "Paper Reviews" Over Treating Physicians

Rather than having you examined, insurers hire doctors (often in different specialties) to review your records and opine you can work. These reviewers never examine you and often lack relevant expertise.

4. Failure to Meet Policy Definition

Insurers argue your condition does not meet the policy's specific definition of disability. This is particularly common during the transition from "own occupation" to "any occupation" periods.

5. Pre-Existing Condition Exclusions

Many policies exclude conditions that existed before coverage began. Insurers sometimes stretch this exclusion beyond its legitimate scope, claiming conditions are pre-existing when they are not.

6. Mental Health Limitations

Most LTD policies limit benefits for mental health conditions to 24 months. Insurers may improperly characterize physical conditions as mental health conditions to trigger this limitation.

ERISA vs. State Law Claims

The type of policy you have dramatically affects your legal rights and strategy:

The ERISA Appeals Process

If your LTD plan is governed by ERISA, you must exhaust administrative remedies before filing a lawsuit. This process is your one chance to build a complete record.

Why the Administrative Appeal Matters

In ERISA cases, courts typically review only the evidence in the administrative record. This means whatever evidence you submit during your appeal is often all the judge will consider. You cannot save strong evidence for court.

Steps to a Strong ERISA Appeal

1. Request the Complete Claim File: ERISA requires insurers to provide your complete file upon request. Review every document they relied upon.
2. Identify the Specific Reasons for Denial: The denial letter must explain why your claim was denied. Each reason needs a targeted response.
3. Obtain Supporting Medical Evidence: Get detailed narrative reports from your treating physicians explaining why you cannot work, addressing the specific denial reasons.
4. Consider Independent Expert Reviews: Vocational experts, medical specialists, and other experts can rebut the insurer's conclusions.
5. Submit a Comprehensive Appeal: Address every denial reason with evidence, include a legal argument, and ensure everything is in the record.
6. Meet the Deadline: You typically have 180 days to appeal. Missing this deadline can waive your rights.

Building Your Medical Evidence

Strong medical evidence is the foundation of any successful LTD claim. Here is what I typically recommend:

Treating Physician Statements

Your treating doctors know your condition best. Request detailed narrative letters that:

• Describe your diagnosis, prognosis, and treatment plan
• Explain your specific functional limitations (standing, sitting, lifting, concentrating)
• Address why you cannot perform your job duties
• Respond to any contrary opinions in the denial letter

Functional Capacity Evaluation (FCE)

An FCE is an objective assessment of your physical abilities performed by a physical therapist. While insurers sometimes challenge FCE results, a well-conducted FCE provides powerful objective evidence.

Neuropsychological Testing

For cognitive conditions (brain injuries, chronic fatigue, fibromyalgia, long COVID), neuropsychological testing can document deficits that standard medical exams miss.

Vocational Expert Opinion

A vocational expert can analyze your limitations against the demands of your occupation (and other occupations) to support that you cannot work.

Common LTD Policy Provisions

Elimination Period

The waiting period before benefits begin, typically 90-180 days. You must remain continuously disabled during this period. Some policies allow you to work part-time during elimination without losing eligibility.

Own Occupation vs. Any Occupation

Most policies pay benefits if you cannot perform your "own occupation" for the first 24 months. After that, the definition often changes to "any occupation." This transition point is when many claims get terminated.

Offset Provisions

Benefits may be reduced by Social Security disability payments, workers' compensation, and other income. Understand your policy's offset provisions to calculate your actual benefit.

Mental Health Limitations

Most policies limit mental health benefits to 24 months. Insurers sometimes misclassify conditions like chronic fatigue syndrome or fibromyalgia as mental health conditions to apply this limitation.

For a detailed explanation of the own occupation vs. any occupation distinction, see my guide on Own Occupation vs. Any Occupation.

What to Do When Your Claim Is Denied

Immediate Steps

1. Do Not Panic: Denials are common, and many are successfully overturned on appeal.
2. Note the Deadline: Mark your appeal deadline on your calendar immediately.
3. Request Your Complete File: You have a legal right to obtain your entire claim file.
4. Continue Medical Treatment: Gaps in treatment can be used against you.
5. Document Everything: Keep notes of all communications with the insurer.

Consider Legal Help

LTD appeals, especially under ERISA, are complex. The administrative record you create may be the only evidence a court considers. Many experienced attorneys offer free consultations to evaluate your case.

Do Not Give Up

Insurance companies deny claims knowing that many people will simply give up. The appeals process exists because legitimate claims are frequently denied. If you are truly disabled, fight for your benefits.