What Happens When You Appeal an LTD Denial

When your long-term disability 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 an appeals examiner or claims specialist, who reads your file from the start. This person has no stake in the original decision and is required to consider new medical evidence you submit.

The timeline and procedure depend on whether your LTD plan is governed by ERISA (Employee Retirement Income Security Act), which covers most employer-sponsored disability plans. ERISA plans have strict important date and specific steps you must follow, and missing a important date can lock you out of further appeals. If your plan is not ERISA-governed — for example, if you bought individual disability insurance on your own — your state's insurance laws explore instead, and the rules differ.

You will need to submit a written request for appeal, gather medical records that support your claim, and sometimes obtain a statement from your treating doctor. The appeals examiner will then review everything and issue a decision, usually within 30 to 60 days for ERISA plans.

Key Takeaways

  • ERISA plans require you to request an appeal in writing within 180 days of the denial letter, or you lose the right to appeal through the plan.
  • You must submit new or updated medical evidence with your appeal — the same records that were already reviewed will not change the outcome.
  • The appeals examiner is a different person from the original decision-maker and must consider all evidence you provide before issuing a new decision.
  • If the plan denies your appeal, you can file a lawsuit in federal court, but only after exhausting the plan's appeal process.
  • Non-ERISA plans (individual policies) follow state insurance law and may have different timelines and appeal procedures.

Understanding the Appeal important date and How to Request One

The first step is to locate your denial letter and check the date it was sent. ERISA plans give you 180 days from the date of the denial to request an appeal in writing. This is a hard important date — if you miss it, the plan can refuse to hear your appeal, and you will have no recourse except to file a lawsuit (which is expensive and uncertain). If you cannot find the original denial letter, contact your plan administrator or your employer's benefits department and ask them to send you a copy.

To request an appeal, write a letter to the address listed in your denial letter under "Appeals" or "How to Appeal." Keep the letter straightforward: state your name, your policy or claim number, the date of the original denial, and a sentence saying you are requesting a full appeal of that decision. Send it by certified mail with return receipt so you have proof of when it arrived. Do not wait until day 179 — mail delays happen, and you want a buffer.

Some plans also accept appeal requests online through their member portal or by phone. Check your denial letter for those options. Whichever method you use, keep a copy of everything you send and note the date and time.

Gathering Medical Evidence to Support Your Appeal

The reason your claim was denied is stated in the denial letter — usually something like "insufficient medical evidence of disability" or "your condition does not meet the plan's definition of disability." Your appeal must address that specific reason by providing evidence the original reviewer did not have or did not properly consider.

Start by collecting all medical records from the date you stopped working through the present: office visit notes, test results, imaging reports, hospital discharge summaries, and any mental health treatment records. Ask your doctor's office to send these directly to you in writing, not just verbally. Then review your original denial letter and identify what medical information was missing or what the plan said was insufficient. For example, if the plan said your doctor did not document your functional limitations, you now need a detailed statement from your doctor describing what you cannot do.

Contact your treating physician — the doctor who knows your condition best — and ask them to write a letter specifically addressing the plan's reason for denial. The letter should be detailed: instead of "Patient is disabled," it should say "Patient cannot sit for more than 30 minutes without severe back pain, cannot lift more than 10 pounds, and cannot perform sedentary work due to cognitive fog from medication." Provide the doctor with a copy of the denial letter so they understand what the plan is questioning. This letter is often the most important piece of your appeal.

If you have seen a specialist since the original denial, include their records too. If you have been hospitalized, had surgery, or started new treatment, all of that is relevant. The goal is to show the appeals examiner that your medical condition has not improved or has worsened, or that the original records straightforward did not capture the full picture.

What to Include in Your Written Appeal

Your appeal should be a single package: a cover letter, your written statement, the medical evidence, and your doctor's letter. Number the pages and include a table of contents so the appeals examiner can find things easily.

The cover letter should be brief — one page. State your name, policy number, and claim number. Say that you are appealing the denial dated [date]. List what you are enclosing: "This appeal includes my written statement, medical records from [dates], and a letter from Dr. [name] dated [date]." Do not argue or get emotional in the cover letter; save that for your statement.

Your written statement should be two to four pages. Describe your daily life: what you can and cannot do, how your condition affects your ability to work, what medications you take and their side effects, and how your condition has changed since the original claim. Be specific and honest. If you tried to return to work and could not, describe what happened. If you have good days and bad days, explain that. The appeals examiner wants to understand your actual experience, not a legal argument.

Organize your medical records in chronological order, starting with the most recent. Include a sticky note or highlighter marking the sections that directly support your claim. Do not submit your entire medical file if it is hundreds of pages — focus on the records that matter to your case.

The Appeals Examiner's Review and Decision Timeline

Once you submit your appeal, the plan has 30 days to acknowledge receipt and tell you when you can expect a decision. For ERISA plans, the appeals examiner must issue a written decision within 60 days of receiving your appeal, though some plans take the full 60 days as standard. Non-ERISA plans may have different timelines depending on your state's insurance law.

During this time, the appeals examiner will read your entire file: the original claim, the original denial, and everything you submitted with your appeal. They may request additional information from you or your doctor. If they do, respond quickly — delays on your end can extend the timeline.

The appeals examiner's decision will come in writing and will explain their reasoning. If they overturn the denial, the plan will begin paying your benefits, usually within two to four weeks. If they uphold the denial, the letter will explain why and will tell you what your next options are, including whether you can file a lawsuit.

What to Do If Your Appeal Is Denied

If the plan denies your appeal, you have limited options. For ERISA plans, you can file a lawsuit in federal court, but you must do so within three years of the denial (the statute of limitations). Before you sue, understand that you will need to hire a disability attorney, which is expensive, and you will need to prove the plan's decision was wrong — not just that you disagree with it.

Some people pursue a second appeal if their medical condition has significantly worsened or if they have new medical evidence that is substantially different from what they submitted the first time. The plan is not required to hear a second appeal, but you can request one. This is worth doing only if you have genuinely new information, not just a restatement of the old information.

If your LTD plan is not ERISA-governed, your state's insurance commissioner may have a complaint process. Contact your state's Department of Insurance and ask whether they handle disability claim disputes. Some states do; others do not.

Common Reasons Appeals Are Denied and How to Address Them

The most common reason for appeal denial is that the medical evidence still does not support the plan's definition of disability. The plan may define disability as "unable to perform any occupation for which you are reasonably suited by education, training, or experience." If your records show you have some functional capacity, the plan may argue you could do desk work, phone work, or other sedentary jobs. To counter this, you need your doctor to state clearly that you cannot perform any work, or that your condition prevents you from working in your field and you have no realistic way to retrain.

Another common reason is that the plan believes your condition is not as severe as you claim, often because you have not been consistent in seeking treatment. If you stopped seeing your doctor for months, the plan may argue your condition improved. If this happened, explain why in your statement — cost, transportation, or depression can all be reasons people stop treatment. Then resume treatment before or during your appeal so you have current medical records.

Some plans deny appeals because they say your condition is pre-existing and excluded under the policy. If this is the reason, review your policy documents carefully. Pre-existing condition exclusions have time limits — usually 12 months — and cannot explore if you disclosed the condition when you enrolled.

Frequently Asked Questions

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

ERISA plans are not required to accept a late appeal, but you can request an exception in writing, explaining why you missed the important date. Some plans grant exceptions for good cause — illness, mail delays, or language barriers. It is worth asking, but do not count on it. If the plan refuses, your only option is to consult a disability attorney about filing a lawsuit.

Do I need a lawyer to appeal?

You do not need a lawyer to file an appeal, and many people handle it themselves. A lawyer is most useful if your case is complex, if the plan has already denied you once, or if you are preparing to sue. Many disability attorneys work on contingency, meaning they take payment only if you win, so it costs you nothing upfront to ask for a consultation.

What if my doctor will not write a letter supporting my appeal?

If your treating doctor will not support your claim, that is a serious problem. Ask them directly why — sometimes doctors are uncomfortable with disability claims or do not understand what the plan needs. Provide them with a copy of the denial letter and a template letter showing what information would be helpful. If they still refuse, consider getting a second opinion from another specialist in your field. A new doctor's records and letter can carry weight in an appeal.

How long does it take to get paid after my appeal is approved?

Once the plan approves your appeal, they typically begin paying benefits within two to four weeks. Back pay — the amount owed from the date your original claim was denied — is usually paid in a lump sum. Confirm the payment schedule with the plan in writing so you know what to expect.

Can the plan deny my appeal without reading the new evidence I submitted?

No. ERISA law requires the appeals examiner to consider all evidence you submit, including evidence that was not in the original file. If the plan denies your appeal without addressing the new medical evidence, that is a violation of ERISA, and you may have grounds for a lawsuit. Keep detailed records of everything you submitted and the dates you submitted it.