What happens when you appeal a long-term disability denial

When your long-term disability (LTD) claim is denied, you have the right to challenge that decision through a formal appeal process. The appeal does not go back to the same person who denied you—it goes to a different reviewer, often called a claims examiner or appeals specialist, who looks at your case from the beginning. This reviewer has the authority to overturn the denial if the evidence supports your claim.

The timeline and process depend on whether your plan is governed by federal law (ERISA) or state law. Most employer-sponsored LTD plans fall under ERISA, which sets strict important date and procedures you must follow. Missing a important date or submitting materials in the wrong format can result in your appeal being rejected without review of the facts.

You will need to gather medical records, work history, and any other evidence that shows you cannot work due to your condition. The insurance company will also review its own file, which may include surveillance, medical exams they ordered, or statements from your employer. Your job in the appeal is to show why their reason for denial was wrong.

Key Takeaways

  • ERISA plans require you to submit your appeal within 180 days of the denial letter, and the insurance company must respond within 60 days for non-disability claims or 72 hours for claims involving ongoing benefits.
  • You must include new medical evidence or explain why the original evidence contradicts the denial reason—submitting the same documents without explanation rarely succeeds.
  • Request the full claims file from the insurance company before you appeal, because you need to know what evidence they used to deny you.
  • If the appeal is denied, you may have the right to file a lawsuit in federal court, but only if your plan is ERISA-governed and you have exhausted the appeal process first.

Obtain your complete claims file before appealing

Before you write your appeal, you must request the entire claims file from the insurance company. This file contains every document they reviewed when they made the denial decision—medical records they obtained, notes from their medical reviewer, statements from your employer, and the specific reason they denied you. You cannot effectively challenge a decision if you do not know what evidence they relied on.

Send a written request to the claims department or appeals department (the denial letter will list the address). Ask for "the complete claims file" or "all documents in the file." Under ERISA, the insurance company must provide this within 30 days at no cost. Keep a copy of your request and note the date you sent it.

Once you have the file, read the denial reason carefully. Common reasons include: insufficient medical evidence of disability, your condition does not meet the plan definition of disability, you are capable of performing some type of work, or your medical records do not support the severity you claim. Your appeal must directly address the reason given, not just restate your symptoms.

Gather new medical evidence or clarification from your doctors

The most common reason appeals fail is that they submit the same medical records that were already in the file. The insurance company already reviewed those records and found them insufficient. Your appeal needs something different: either new medical evidence (test results, imaging, treatment records from after the denial) or a detailed letter from your treating doctor that explains why the existing records prove disability.

Contact your doctor and ask them to write a letter addressing the specific denial reason. For example, if the denial said your condition does not prevent all work, ask your doctor to explain in writing why you cannot perform your job duties or any job. If the denial said your medical records lack objective findings, ask your doctor to order the tests that will produce those findings—imaging, nerve conduction studies, functional capacity evaluations, or psychological testing.

Do not ask your doctor to straightforward say you are disabled. Ask them to explain how your condition limits your ability to sit, stand, concentrate, remember instructions, or perform the specific tasks your job requires. The more specific the letter, the harder it is for the insurance company to dismiss it as conclusory.

Write your appeal letter with a clear structure

Your appeal letter should be organized and straightforward to follow. Start by stating your claim number, the date of the denial, and the reason the company gave for denying you. Then, point by point, explain why that reason is wrong. Do not argue in general terms—reference specific medical records, dates, and findings.

Structure your letter like this: (1) restate the denial reason, (2) cite the medical evidence that contradicts it, (3) explain what that evidence means, and (4) state how it proves you meet the plan definition of disability. For example: "The denial stated my condition does not prevent all work. However, Dr. Smith's functional capacity evaluation dated [date] concluded I cannot sit for more than 30 minutes without severe pain. My job requires sitting 8 hours daily. Therefore, I cannot perform my job or any job."

Keep the letter concise—three to five pages is typical. Organize your documents in the order you reference them. Number each page. Include a cover letter that lists what you are submitting (medical records, doctor's letter, functional capacity evaluation, etc.). This makes it easier for the reviewer to follow your argument.

Meet the important date and submit correctly

If your plan is ERISA-governed, you have 180 days from the date of the denial letter to file your appeal. This is a hard important date. If you miss it, you lose the right to appeal within the plan and may have to go directly to court (which is more expensive and uncertain). Mark the important date on your calendar and submit at least two weeks early.

Check the denial letter for the correct address to send your appeal. Some companies have a separate appeals department address. Send your appeal by certified mail with return receipt requested, or use a delivery method that provides proof of receipt. Keep copies of everything you send.

If your plan is governed by state law rather than ERISA, the important date may be different—typically 30 to 60 days. Check your plan documents or call the claims department to confirm which law governs your plan and what the important date is.

What to expect during the appeal review

Once you submit your appeal, the insurance company must acknowledge receipt and tell you when you can expect a decision. Under ERISA, they have 60 days to respond for most claims, or 72 hours if you are currently receiving benefits and the appeal is about continuing those benefits. Some plans allow longer timelines if they need to obtain additional medical records.

During the review, a different examiner will read your appeal letter, your new medical evidence, and the original claims file. They may order their own medical exam or send your records to a medical consultant for review. You will not attend a hearing or speak to the reviewer unless your plan specifically provides for one (most do not).

The decision will come in writing. If approved, the letter will explain what benefits you are may have access to to and when payments begin. If denied again, the letter must explain the reason and tell you what appeal rights remain—usually the right to file a lawsuit in federal court if your plan is ERISA-governed.

What happens if your appeal is denied

If the appeal is denied and your plan is ERISA-governed, you have the right to file a lawsuit in federal court. You must do this within the time limit set by your plan documents (usually one to three years from the denial). However, you can only sue if you have completed the appeal process first—courts will not hear a case if you skipped the appeal step.

If your plan is governed by state law, you may have the right to appeal to your state insurance commissioner or file a complaint with your state's department of insurance. Some states also allow you to file a lawsuit in state court. Check your plan documents or contact your state insurance commissioner's office to learn what options are available.

Before you file a lawsuit, consider consulting with a disability attorney. Many work on contingency, meaning they take a percentage of any settlement or judgment rather than charging you upfront. An attorney can review your case and tell you whether a lawsuit is likely to succeed.

Frequently Asked Questions

Can I appeal if I missed the 180-day important date?

Under ERISA, missing the important date means you lose the right to appeal within the plan. However, some courts have allowed late appeals if the insurance company did not clearly inform you of the important date or if you had good reason for the delay. Contact a disability attorney when ready if you missed the important date—they can advise whether you have any options.

Should I hire a lawyer to appeal?

Many people successfully appeal without a lawyer by gathering strong medical evidence and writing a clear letter. However, if the denial reason is complex, if you have already appealed once, or if the amount of benefits is substantial, an attorney can improve your chances. Many offer free consultations.

What if the insurance company says they need more time to decide?

Under ERISA, they can extend the important date by up to 14 days if they notify you in writing before the original important date expires and explain why they need more time. If they extend beyond that without your agreement, you may have grounds to treat the appeal as approved. Ask them in writing to confirm the new important date.

Can I submit new evidence after I file my appeal?

Yes, but submit it quickly. Send a letter saying "Supplemental evidence for appeal of claim [number]" and include the new documents. The insurance company should consider anything you submit before they issue a decision, though they are not required to wait for late submissions.

What if my employer's records contradict my claim?

Address this directly in your appeal. If your employer reported you were working or performing duties you claim you cannot do, explain the discrepancy. For example, if you worked part-time after the disability began, explain that you could only do so with significant pain or accommodation, or that your condition worsened after that work ended. Get a letter from your doctor supporting your explanation.