Your long-term disability claim was denied. Your doctor says you cannot work, the insurance company says you can, and the letter says you have 180 days to appeal. Should you write the appeal yourself, ask your doctor for another note, or hire a lawyer?
You have every right to appeal on your own, and some denials can be fixed without a lawyer. But before you decide, you need to understand one thing about how ERISA appeals work, because it is the opposite of what most people expect.
You can appeal without a lawyer
Most LTD plans that come through an employer are governed by ERISA, a federal law that sets the procedure for appealing a denied disability claim. You generally have at least 180 days. You can write the appeal yourself and send any medical records, doctor’s statements, and other evidence you want.
What the law does not do is require the insurance company to approve your claim because your doctor says you are disabled. The real question is whether you know what evidence the insurer needs to see and how to answer its reasons for denial.
ERISA does not cover every policy. A policy you bought yourself, and some government and church plans, follow different rules. More: ERISA plan or private policy?
The biggest danger: you may not get another chance to submit evidence
In Social Security disability cases, I can usually add new medical evidence as a case moves from the initial application to reconsideration to a hearing. ERISA cases do not work that way.
If your appeal is denied, you may be able to sue in federal court. But in many ERISA cases the judge reviews only the evidence in the administrative record, the file the insurance company had when it made its final decision. You cannot count on being allowed to add new medical reports, doctor’s opinions, or vocational evaluations once a lawsuit is filed. There are exceptions, and the rules vary by court and by the standard of review, but evidence left out of the appeal may be difficult or impossible to add later.
Here is how that plays out. A claimant with severe lumbar spine problems sends a two-page letter and a few medical records. The appeal is denied. Then he hires a lawyer, who finds that:
- the insurer’s medical reviewer misread the MRI,
- the vocational report relied on the wrong sitting restrictions,
- the treating physician never gave a detailed functional assessment, and
- nobody addressed his medication side effects.
All of those problems were fixable during the appeal. Now they may not be.
Your appeal has to answer the reason you were denied
More medical records are not always more evidence. Say the insurance company’s reviewing doctor concludes you can sit for six hours a day, and you answer by sending another MRI. The insurer may not dispute your diagnosis at all. The disagreement is about whether you can sit and keep working.
A useful answer is a detailed opinion from your treating physician on:
- how long you can sit at one time and in a day,
- how often you need to change positions,
- whether you need unscheduled breaks, and how many,
- how pain affects your concentration, and
- how many days a month you are likely to miss.
If the insurance company says you can sit six hours, your appeal has to explain, with evidence, why you cannot.
What a lawyer does on an LTD appeal
An appeal is not just a request to reconsider. It is your chance to challenge the evidence the insurer relied on and to build the record. On an appeal, I:
- Get and review the complete claim file: the records the insurer considered, its doctors’ reports, its vocational assessments, and any factual mistakes or missing evidence.
- Analyze the policy: whether the insurer applied the right definition of disability, the own-occupation and any-occupation provisions, any earnings requirement, exclusions, limitations, and deadlines.
- Develop medical evidence: detailed functional assessments, treating physician responses to the insurer’s reviews, and evidence on pain, fatigue, concentration, and attendance.
- Challenge vocational conclusions: whether you have the skills for the jobs the insurer named, whether those jobs fit your restrictions, and whether its wage data is right.
- Check the insurer’s procedure: whether it explained its reasons, gave you the documents you asked for, and gave you a chance to respond to any new evidence or reasoning before deciding your appeal.
What if you cannot afford a lawyer?
Find out how the lawyer charges before you decide. LTD lawyers use different arrangements: contingency fees, hourly fees, flat fees, or a combination. Read any fee agreement carefully to see whether the fee applies to back benefits, future monthly benefits, or both.
At our firm, we do not take a fee from any future monthly benefit. We explain the rest of our fee terms at the free consultation.
LTD fees are also not set by the fee approval system that applies to Social Security disability cases. In some ERISA lawsuits a court may award attorney’s fees, but that is up to the judge and is not automatic.
When handling your own appeal may be reasonable
Not every denial needs a lawyer. You might handle it yourself when the problem is a straightforward administrative issue, a specific missing record, or a reason you can clearly answer with evidence you already have.
For example: the claim was denied because the insurer never received a required physician statement, and you can confirm your doctor completed it and send it with supporting records.
Even then, read the whole denial letter and the policy first. A denial that looks simple can hide a second issue.
When you should strongly consider a lawyer
- The insurer relies on an IME or a medical records review that contradicts your doctors.
- A vocational expert has named other jobs you supposedly can do.
- Your claim involves chronic pain, fatigue, mental health, or symptoms that come and go.
- Your benefits ended when the policy switched from own occupation to any occupation.
- The insurer says surveillance contradicts your reported limits.
- A lot of money is at stake.
On the last point: a 52-year-old professional receiving $6,000 a month is cut off after two years based on a vocational report. If the policy could pay another ten years of benefits, that appeal is worth over $700,000. It is not something to approach casually.
Do not wait until the last month
A good appeal takes time. The claim file can take weeks to arrive. Doctors need time to write detailed reports. Testing, a functional capacity evaluation, or a vocational review may be needed. If you set the denial letter aside for five months, you will run out of time to build the evidence.
CTA: Was your LTD claim denied? Call 770-351-0801 or request a free case evaluation before you file your appeal. Whatever you decide, watch your deadline.
Related: Recently denied? · Why ERISA favors insurance companies · Can I sue in federal court?