What happens when you file a long-term disability claim

When you file a long-term disability (LTD) claim, you are asking your insurance company to pay you monthly benefits because you cannot work due to illness or injury. The insurer will assign a claims examiner to your case, request medical records, and decide whether your condition meets the policy's definition of disability. This process typically takes 30 to 90 days, though complex cases take longer. The insurer is not required to approve your claim just because you stopped working—they must find that your medical evidence supports the specific definition written in your policy.

Most LTD policies define disability in two stages. During the first 24 months (called the "own occupation" period), you are disabled if you cannot do your own job. After 24 months, the definition usually shifts to "any occupation"—meaning you are disabled only if you cannot do any job you are reasonably suited for by education, training, or experience. This shift is why many claims are approved early but denied later, even if your condition has not improved.

If the insurer denies your claim, you have the right to appeal. The appeal process varies by policy but usually involves submitting additional medical evidence and a written response to the denial reason. Many denials are reversed on appeal, especially when you add new medical records or informed statements that directly address the insurer's stated reason for denial.

Key Takeaways

  • Your policy's definition of disability controls whether you win—not whether you are unable to work in general, so read your policy document before filing.
  • The insurer will request medical records from your doctors, so contact them when ready after filing and ask them to send records directly to the claims examiner.
  • Most policies shift from "own occupation" to "any occupation" after 24 months, which is why claims approved early are sometimes denied later.
  • If denied, you can appeal by submitting additional medical evidence and a written response; many denials are reversed on appeal when new evidence directly addresses the denial reason.
  • A disability lawyer can review your policy, identify weaknesses in the insurer's reasoning, and represent you in the appeal process.

Read your policy before you file

Your LTD policy is a contract, and the insurer will interpret it strictly in their favor. Before you file, obtain a copy of your policy document—usually available through your employer's benefits office or your insurer's website—and read the definition of disability word for word. Write down the exact language. Many policies require that you be unable to work "due to sickness or injury," while others add language like "as determined by a physician" or "as evidenced by objective medical findings." Some policies exclude certain conditions, such as mental health disorders or back pain without imaging confirmation.

Pay special attention to the own-occupation versus any-occupation shift. If your policy says you are disabled under own occupation for 24 months and then any occupation thereafter, mark that date on your calendar. This is a critical important date because the insurer will often use this transition to deny a claim that was previously approved. If you are still unable to work at month 25, you will need to prove you cannot do any job you are reasonably suited for—a much harder standard.

If your policy is unclear or you cannot find a copy, contact your employer's human resources or benefits department and ask for the Summary Plan Description (SPD) and the full policy document. If you are self-employed or have an individual policy, contact your insurance agent or the insurer directly. Do not file without understanding what you are claiming under.

Gather medical evidence before filing

The insurer will make their decision based almost entirely on medical records. Before you file, schedule appointments with your treating physicians—the doctors who know your condition best—and tell them you are filing for long-term disability. Ask each doctor to document in your medical record how your condition limits your ability to work. Be specific: instead of "patient reports fatigue," the record should say "patient reports inability to concentrate for more than 30 minutes at a time, which prevents return to office work requiring sustained focus."

Collect records from every provider who has treated you for the condition causing your disability. This includes your primary care doctor, specialists, mental health providers, physical therapists, and any emergency room or hospital visits. Request records going back at least two years, even if some are older. The insurer will look for a pattern showing your condition is ongoing and severe, not a temporary setback.

If your treating doctors have not documented your functional limitations clearly, ask them to write a detailed letter or complete a medical questionnaire specifically for your disability claim. Many insurers provide a form for doctors to complete; ask your claims examiner to send it to your doctors. A well-completed form from your doctor carries significant weight because it comes from someone with direct knowledge of your condition and is harder for the insurer to dismiss.

File your claim and notify the insurer of your medical records

File your claim through your employer's benefits office or directly with the insurer, depending on your policy. You will need to complete a claim form that asks about your work history, the date you stopped working, your job duties, and a description of your condition. Be thorough and honest. Do not minimize your symptoms or overstate them—the insurer will compare your written statement to your medical records, and inconsistencies will be used against you.

Once you have filed, contact your treating physicians when ready and ask them to send all relevant medical records directly to the claims examiner. Provide them with the claims examiner's name, address, and fax number. Do not wait for the insurer to request records—many claims are delayed or denied because doctors do not respond to insurer requests, or respond slowly. By sending records proactively, you control the timeline and may support the examiner has what they need.

Keep a log of every document you send to the insurer and every conversation you have with the claims examiner. Write down the date, the examiner's name, what was discussed, and what was promised. This record will be invaluable if you need to appeal or if the insurer later claims they never received something you sent.

Understand the insurer's reason if they deny your claim

If your claim is denied, the insurer must provide a written explanation. Common denial reasons include: insufficient medical evidence of disability, medical records that do not support the policy's definition, a gap in treatment (the insurer interprets this as improvement), or a information that you can perform other work. Read the denial letter carefully and identify the specific reason given. This reason is your roadmap for the appeal.

Many denials are based on a misreading of your medical records or a failure to consider all the evidence. For example, an insurer might deny a claim for depression by pointing to a gap in psychiatric visits, without considering that the gap occurred because you were unable to afford treatment or could not find a provider. Another common error is the insurer's conclusion that you can perform "sedentary work" based on a single sentence in a medical record, without considering your other limitations or the actual demands of sedentary jobs.

Do not assume the denial is final. The appeal process is where many claims are won, because you have the opportunity to submit new evidence and directly challenge the insurer's reasoning. If you do not understand why you were denied, or if you believe the denial is wrong, an appeal is your next step.

Appeal with new medical evidence and a written response

Your policy gives you the right to appeal within a set time frame—usually 30 to 180 days from the denial letter, depending on your policy. Do not miss this important date. To appeal, submit a written statement explaining why you disagree with the denial and include new or additional medical evidence that addresses the insurer's stated reason for denial.

The key to a successful appeal is specificity. If the insurer denied your claim because they said your medical records lack objective findings, submit new records that include test results, imaging, or clinical observations. If they denied it because they believe you can perform sedentary work, submit a detailed letter from your doctor explaining why you cannot sit for the periods required by sedentary jobs, or submit evidence of your attempts to work and why they failed. Do not straightforward resubmit the same records and argue the insurer was wrong—add something new that directly answers their stated reason.

Write your appeal letter in plain language, point by point. For each reason the insurer gave for denial, write a paragraph explaining why that reason is incorrect and cite the medical evidence that supports your position. For example: "The insurer states my medical records lack objective findings. However, the MRI from [date] shows [specific finding], and Dr. [name]'s examination on [date] documented [specific clinical finding]. These objective findings support my treating physician's opinion that I cannot return to work."

When to involve a disability lawyer

A disability lawyer can review your policy, identify weaknesses in the insurer's reasoning, and represent you in the appeal process. Lawyers are especially valuable if your claim was denied, if the insurer is requesting extensive additional medical records, or if your policy contains language you do not understand. Many disability lawyers work on contingency, meaning they take a percentage of any back pay you receive if you win—you do not pay out of pocket upfront.

A lawyer can also help you understand the shift from own-occupation to any-occupation coverage and prepare for the insurer's likely arguments at that transition point. If you are approaching month 24 of your claim, consulting a lawyer before the shift occurs can help you gather the right evidence to support your position under the stricter any-occupation standard.

You do not need a lawyer to file or appeal a claim, but having one significantly increases your chances of winning, especially in complex cases or after a denial. If cost is a concern, many lawyers offer free initial consultations and can advise you on whether your case is strong enough to warrant representation.

Frequently Asked Questions

How long does it take to get a decision on my claim?

Most insurers make an initial decision within 30 to 90 days of receiving your complete claim file. Complex cases or cases requiring additional medical records can take longer. If the insurer requests more information, the clock may restart. Ask your claims examiner for a specific timeline and follow up if you do not hear back within the stated period.

What if my doctor will not complete the insurer's medical form?

Contact your doctor's office and explain that the form is required for your disability claim. Many offices will complete forms if you provide them with a stamped, addressed envelope and a important date. If your doctor refuses, ask why and consider whether another treating provider can complete the form instead. A refusal from your doctor may signal that they do not believe your condition prevents work, which will hurt your claim.

Can the insurer deny my claim because I am receiving Social Security Disability?

No. Your LTD policy and Social Security Disability Insurance (SSDI) are separate programs with different definitions of disability. However, most LTD policies require you to explore for SSDI if you are may be able to access, and they will offset (reduce) your LTD benefit by the amount you receive from SSDI. The insurer cannot deny your LTD claim solely because you are receiving SSDI, but they can reduce your payment.

What happens if I return to work part-time while my claim is pending?

Report any work or income to your claims examiner when ready. Many policies allow partial disability benefits if you are working but earning less than you did before your condition began. However, if you do not report work and the insurer discovers it later, they may deny your claim or demand repayment of benefits. Transparency protects you.

How do I know if my appeal was successful?

The insurer must provide a written decision on your appeal, usually within 30 to 60 days of receiving it. If approved, they will explain the effective date of benefits and how much you will receive monthly. If denied again, they must explain their reason and your right to further appeal or legal action. Keep all appeal decisions in a file for your records.