What a long-term disability claim is

A long-term disability claim is a request for benefits from an insurance policy that replaces part of your income when you cannot work due to illness or injury. Unlike Social Security Disability Insurance (SSDI), which is a federal program, long-term disability is usually provided through your employer or purchased privately. The insurance company decides whether to pay based on the policy terms and the medical evidence you submit.

Long-term disability typically kicks in after a waiting period—often 90 days or six months—during which you use sick leave or short-term disability. Once approved, the policy usually replaces 50 to 70 percent of your salary, though the exact amount depends on what your policy says. Payments continue until you return to work, reach retirement age, or the policy term ends, whichever comes first.

Key Takeaways

  • Long-term disability is an insurance benefit, not a government program, and the rules depend entirely on what your specific policy says.
  • The insurance company will ask for medical records, test results, and statements from your doctors before deciding whether to pay.
  • If your claim is denied, you have the right to appeal, and a disability lawyer can help you gather evidence and challenge the decision.
  • Long-term disability and SSDI are separate programs—you can receive both at the same time, though SSDI payments may reduce your disability insurance benefit.
  • The claims process usually takes several weeks to several months, and the insurance company may request updated medical information while you are receiving benefits.

Where long-term disability comes from

Long-term disability insurance is most commonly offered through your employer as part of your benefits package. Some employers self-insure, meaning they pay claims directly from company funds. Others buy a policy from an insurance company like Unum, MetLife, or Cigna. If you are self-employed or your employer does not offer coverage, you can purchase an individual long-term disability policy from an insurance broker, though these are more expensive and have stricter underwriting.

Your policy document—sometimes called the Summary Plan Description or SPD—contains the specific rules: how long you must wait before benefits start, what percentage of your income is replaced, what counts as a disability under that policy, and how long you can receive payments. If you do not have a copy, ask your employer's human resources or benefits department. If you bought the policy yourself, check your insurance company's website or your original paperwork.

What the insurance company needs from you

When you file a claim, the insurance company will send you a form asking about your condition, your job duties, and when you stopped working. You will also need to authorize the release of your medical records. The insurance company then contacts your doctors directly to request documentation: office visit notes, test results, imaging reports, diagnoses, and the doctor's opinion on whether you can work.

The strength of your claim depends on how clearly your medical records show that your condition prevents you from doing your job. If your records are sparse or vague, the insurance company is more likely to deny the claim. This is where a disability lawyer becomes valuable—they know what medical evidence carries weight and can advise you on what to ask your doctor to document. They can also request that your doctor write a detailed statement explaining why you cannot work, not just that you are ill.

The insurance company may also hire its own doctor to review your records or request that you see a doctor of their choosing. This is called an independent medical examination (IME). You are required to attend, and the insurance company pays for it. The IME doctor's opinion can influence the decision, so it helps to bring a list of your symptoms and limitations to the appointment.

How the decision is made

The insurance company reviews your medical records, the IME report (if one was done), and your job description to decide whether you meet the policy's definition of disability. Most policies use one of two definitions: "own occupation" or "any occupation." Under own occupation, you are disabled if you cannot do your specific job. Under any occupation, you are disabled only if you cannot do any job you are reasonably suited for by training or experience.

Own occupation is more favorable to you—it is easier to show you cannot be a surgeon than to show you cannot work at all. Check your policy to see which definition applies. The insurance company will also verify that you are actually not working and that you are not earning income from another source.

The decision letter will say whether your claim is approved, denied, or approved with conditions. If approved, it will state the monthly benefit amount and when payments begin. If denied, it must explain the reason—usually that the medical evidence does not support the claim or that your condition does not meet the policy definition of disability.

What happens if your claim is denied

A denial is not final. Your policy includes an appeal process, and you have a limited time to use it—often 30 to 90 days from the denial letter. To appeal, you submit a written request and additional evidence that addresses the reason for the denial. If the company said the medical evidence was insufficient, you submit more detailed records or a new statement from your doctor. If the company said you do not meet the definition of disability, you submit evidence that directly contradicts that conclusion.

Many people lose appeals because they straightforward resubmit the same documents. A disability lawyer reviews the denial letter, identifies what evidence would change the outcome, and directs you to gather it. They also know how to frame the appeal letter to address the insurance company's specific objections rather than making a general argument.

If the appeal is also denied, you may have the right to file a lawsuit, but this depends on your policy and your state's laws. Some policies require arbitration instead of court. A disability lawyer can tell you what your options are and whether pursuing further action makes financial sense.

Long-term disability and SSDI at the same time

You can receive both long-term disability and SSDI simultaneously. However, many long-term disability policies include an "offset" clause that reduces your monthly benefit by the amount you receive from SSDI. For example, if your policy pays $3,000 per month and you are awarded $1,500 in SSDI, your disability insurance payment drops to $1,500.

Some policies also require you to explore for SSDI as a condition of receiving long-term disability. If your policy has this requirement and you do not explore, the insurance company can deny or stop your benefits. A disability lawyer can review your policy to explain how SSDI will affect your payments and whether you are required to pursue it.

How long payments continue

The duration of long-term disability benefits varies by policy. Some policies pay until age 65 or 67. Others pay for a set number of years—two years, five years, or until retirement age, whichever comes first. A few policies pay indefinitely if you remain disabled, though these are rare and expensive.

While you are receiving benefits, the insurance company may periodically request updated medical records to confirm you are still disabled. You are required to cooperate with these requests. If you return to work, even part-time, you must report it when ready. Many policies allow you to earn a small amount without losing benefits, but exceeding that threshold can result in a reduction or termination of payments.

When a disability lawyer helps most

A lawyer becomes most useful when your claim is denied or when the insurance company's offer is lower than you expected. They can also help before you file if your medical records are weak or if your condition is complex. Some lawyers work on contingency, meaning they take a percentage of the back pay you recover rather than charging an hourly fee. Others charge hourly or a flat fee.

Because long-term disability is a contract between you and an insurance company—not a government program—the rules are set by the policy itself. A lawyer who understands insurance law and has experience with your specific insurance company can often identify weaknesses in the company's reasoning and build a stronger case for appeal.

Frequently Asked Questions

How long does it take to get a decision on a long-term disability claim?

Most insurance companies aim to make a decision within 30 to 45 days of receiving your completed claim form and medical records. In practice, it often takes longer if the company requests additional information from your doctors or schedules an independent medical examination. You can ask the insurance company for a timeline when you file.

Can the insurance company stop my benefits if I improve?

Yes. If your medical condition improves enough that you can return to work, the insurance company can terminate your benefits. They may also reduce benefits if you start working part-time. Your policy will specify how much you can earn before benefits are affected. Always report any work activity to the insurance company when ready.

What if my doctor says I am disabled but the insurance company disagrees?

The insurance company is not required to accept your doctor's opinion. They can hire their own doctor to review your case or request that you see a doctor of their choosing. If there is a conflict, the insurance company weighs both opinions. A disability lawyer can help you obtain a more detailed statement from your doctor that directly addresses the insurance company's concerns.

Do I have to repay long-term disability benefits if I return to work?

No. Once benefits are paid, you do not have to repay them. However, if you return to work and your benefits are terminated, future payments stop. Some policies allow a trial work period where you can earn income without losing benefits, so check your policy terms.

Can I work part-time while receiving long-term disability?

It depends on your policy. Some policies allow you to earn a small amount—often $500 to $1,000 per month—without affecting your benefit. Others reduce your benefit dollar-for-dollar based on earnings. A few policies do not allow any work. Review your policy or contact the insurance company to learn what you are permitted to earn.