Long-Term Disability Claims: Denials and Appeals

Being told that your long-term disability claim was denied is hard news, especially when you are already dealing with a health problem and lost income. A denial is a decision, though, not always the final word. Many policies and plans include a way to ask for a second look. This guide explains, in general terms, how denials and appeals usually work and what you can do to prepare.

Private disability insurance vs. Social Security disability

People often mix up two different things. Long-term disability (LTD) coverage is usually a private insurance policy. You may have it through your job, or you may have bought it on your own. The insurance company decides claims under the terms of that policy.

Social Security Disability Insurance (SSDI) is a federal program. According to USAGov's page on SSDI and SSI, SSDI is tied to your work history and pays benefits if you have a disability and worked enough years while paying Social Security taxes. The Social Security Administration has its own process, and USAGov links to the SSA's page on how to appeal a decision if an SSDI application is denied.

The two systems are separate. A denial from a private insurer does not decide your SSDI case, and an SSDI decision does not automatically decide your private claim. Some people have both, and the rules on how one affects the other depend on the policy. Ask about this early, because it can change how much you receive.

Why long-term disability claims get denied

The denial letter should explain the insurer's reasons. Common types of reasons include:

• The insurer says the medical records do not show that you meet the policy's definition of disability.
• Records are missing, out of date, or do not describe your limits in enough detail.
• The insurer says your condition falls under a policy exclusion or limit.
• A form, signature, or deadline was missed.
• The insurer relied on a review by its own doctor or on surveillance or social media.

Read the letter slowly and more than once. Underline every reason and every document it mentions. The reasons in the letter are usually what an appeal needs to answer.

Where your coverage came from matters

If your LTD coverage came through an employer, it may be part of an employee benefit plan. Plans offered through work can be covered by federal rules, including a federal law called ERISA, and those rules can affect how appeals work and what happens if the dispute goes to court. Policies you bought on your own are generally governed by the contract and by state insurance law.

The Employee Benefits Security Administration (EBSA), part of the U.S. Department of Labor, offers information and assistance on employer-sponsored benefit plans. USAGov lists its contact details and toll-free number. A lawyer can tell you which set of rules applies to your coverage.

Steps to take after a denial

1. Find the deadline first

Your denial letter or policy should state how long you have to appeal. Deadlines differ by policy and plan, and missing one can end your chance to appeal. Write the date on your calendar the day you open the letter.

2. Ask for your claim file and policy

Request a copy of the full policy or plan document and the claim file, including the medical reviews the insurer used. Make the request in writing and keep a copy. You cannot respond to reasons you have not seen.

3. Talk to your doctors

Many denials turn on medical evidence. Ask your doctors whether they can describe, in writing, what you can and cannot do during a workday: sitting, standing, lifting, concentrating, and how often symptoms flare. A specific description is often more helpful than a diagnosis alone.

4. Gather other evidence

Useful records may include test results, therapy notes, pharmacy records, a job description from your employer, and statements from people who see your daily limits. Keep a simple log of symptoms and appointments.

5. Write the appeal, or get help writing it

An appeal usually answers the insurer's reasons point by point and adds new evidence. Keep copies of everything you send, and send it in a way you can track.

In many employer plans, the internal appeal is the main chance to add evidence to the record before any lawsuit. That is one reason people often talk to a lawyer before the appeal, not after.

When to talk to a lawyer

You do not need a lawyer to file an appeal. Still, many people choose to get help when:

• The denial says you are not disabled under the policy definition.
• The insurer stopped paying benefits you were already getting.
• You have both an LTD claim and an SSDI claim and are unsure how they interact.
• The appeal deadline is close and the file is large.
• You have already lost an internal appeal.

Disability lawyers often work in employment law, insurance law, or Social Security disability. Ask how often they handle LTD appeals specifically, how the fee works, and who will prepare your appeal. Some lawyers take these cases on a contingency fee, which means they are paid a share of benefits recovered. Get the fee terms in writing.

If cost is a concern, the USAGov legal aid page lists free and low-cost legal help, including groups that serve people with disabilities and older adults.

Mistakes to avoid

• Waiting. Deadlines keep running while you are sick. Start early.
• Sending only a short letter. An appeal without new evidence may lead to the same result.
• Skipping the insurer's reasons. Answer each one.
• Ignoring requests. If the insurer asks for an exam or records, respond or explain in writing why you cannot.
• Assuming the denial is final. Read the letter to learn what options it gives.

Frequently asked questions

How long do I have to appeal a long-term disability denial?

It depends on your policy or plan. The denial letter should state the deadline. If it does not, ask the insurer in writing and talk to a lawyer quickly.

Can I add new medical records in my appeal?

Generally, yes. An appeal is often a key time to add records that answer the insurer's reasons. Ask a lawyer whether there are limits under your plan.

Do I have to apply for Social Security disability too?

It depends on your policy. Some policies say how other benefits, such as SSDI, affect what the policy pays. Read that section of your policy, and ask a lawyer how it works for you.

What if my appeal is denied again?

Depending on the type of coverage, there may be another level of review, a state insurance complaint, or a lawsuit. A lawyer can explain which options are open and how much time you have.

Related: Browse more legal guides and employment lawyers.

General information, not legal advice. Laws change and every case is different — talk to a licensed attorney about your situation.