Common Pitfalls When Appealing Your Long Term Disability Denial

If your Employer offered you long-term disability (LTD) insurance, you expect it to be there when you need it. However, despite all the medical evidence and doctor opinions you provide, insurers still deny valid claims on a routine basis.

While this can feel discouraging, a denial is not necessarily the end of the process. The next step is to file a formal appeal with the insurance company. Because LTD appeals are often complex, mistakes during the process can significantly harm your claim. Below are several common pitfalls to avoid when preparing and submitting an LTD appeal.

1. Filing an Appeal Before Reviewing Your LTD Policy and Claim File

After receiving a denial letter, one of the first things you should do is request a copy of your LTD policy and your complete claim file from the insurance company. You are entitled to these documents at no cost.

Your LTD policy is critical because it outlines the rules governing your claim, including the definition of disability you must satisfy to qualify for benefits. In most cases, you must prove that you are unable to perform the primary duties of your occupation. Understanding these requirements is essential to building a successful appeal.

Your claim file is equally important. It contains the materials submitted with your initial application, such as medical records, physician statements, and claim forms. It also includes documents the insurer relied upon in denying your claim, including reviews from physicians hired by the insurer and vocational assessments identifying the duties of your occupation. Reviewing the claim file helps ensure the insurer considered all relevant evidence and allows you to identify any errors, omissions, or misunderstandings in its decision-making process.

2. Appealing Without Fully Understanding the Basis for the Denial

Insurance companies are required to explain the reasons for denying your claim in the denial letter. Understanding those reasons is essential because a successful appeal must directly address and refute the insurer’s conclusions.

Denials are often based on opinions from medical reviewers or vocational consultants retained by the insurer. In many cases, these opinions are based on incomplete information or misunderstandings regarding your medical conditions or job duties. Your appeal should identify those inaccuracies and include evidence showing why the insurer’s conclusions are incorrect.

3. Failing to Obtain Strong Medical and Vocational Evidence

A persuasive appeal requires more than a written argument. You must submit medical and vocational evidence demonstrating that you cannot perform the duties of your occupation—or, depending on the policy, any occupation.

Helpful supporting evidence may include:

• Updated medical records

• Detailed statements from treating physicians

• Residual functional capacity assessments

• Functional capacity evaluations measuring physical limitations

• Neuropsychological testing for cognitive impairments

• Statements from family members, friends, or coworkers describing how your condition affects your daily functioning

This evidence helps substantiate your symptoms, limitations, and inability to work.

4. Missing the Appeal Deadline

ERISA governed LTD policies have strict deadlines. Most LTD policies require appeals to be submitted within 180 days of the denial date. Missing the deadline can have severe consequences, including the permanent loss of your right to pursue benefits.

We have also seen some insurers try to evade or “dance around” this by accepting and reviewing new medical information after your denial. However, unless you specifically advise the insurer that you want to file an appeal, the new information you provide may not actually trigger an appeal, thus resulting in missing the actual appeal deadline.

5. Ignoring New Evidence Generated During the Appeal Process

Under ERISA regulations, if the insurer obtains new evidence or develops a new rationale for denying your claim during the appeal process, it must provide you with an opportunity to respond before issuing a final decision. This new evidence often includes reports from non-examining physicians or vocational experts hired by the insurer. If you receive such reports, it is important to respond. You should consider forwarding the reports to your treating doctors for review and rebuttal. If additional time is needed, you may request an extension from the insurer.

Carefully reviewing these reports can reveal important issues, such as incomplete medical records, misunderstandings of your condition, or the improper dismissal of your reported symptoms and treating physicians’ opinions.

6. Focusing Too Heavily on Minor Errors and Issues

Individuals handling their own appeals sometimes spend too much time disputing small factual inaccuracies in the denial letter while overlooking the broader reasons for the denial.

Although correcting significant inaccuracies is important, the primary goal of the appeal is to present compelling evidence proving your entitlement to benefits. Rather than preparing a point-by-point rebuttal of every statement in the denial letter, it is generally more effective to focus on strengthening the medical and vocational evidence supporting your claim.

A detailed narrative explaining your symptoms, treatment history, and limitations, combined with updated supporting evidence from your doctors, will usually carry more weight than focusing solely on technical errors in the insurer’s initial decision.

In conclusion, LTD appeals can quickly become legally and medically complicated. Because the outcome of your appeal may determine your financial stability while dealing with serious health conditions, consulting an experienced disability benefits attorney can be extremely valuable.

An attorney can help gather the appropriate evidence, identify weaknesses in the insurer’s reasoning, ensure deadlines are met, and present the strongest possible case for approval of your benefits claim.

If you have been denied LTD benefits and want to consult with an attorney at no cost, contact Operana Law Office today at 800-999-1969.