Submitting an Effective LTD Appeal

Fighting for Your Denied Disability Benefits

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Can I Overturn a Denied Disability Insurance Claim?

Receiving a disability insurance claim denial can be incredibly discouraging, especially when you are already struggling with health issues and financial uncertainty. At Dorian Law, we understand the added stress a denial brings. Please know that a denial is not always the final word. You have the right to appeal, and submitting a strong, effective appeal is crucial to securing the disability benefits you deserve. Dorian Law is here to guide you through this process and champion your appeal.

It's understandable to feel defeated after a disability claim denial. You may be tempted to give up. However, appealing is often a necessary and very worthwhile step. Insurance companies, even with disability claims, can make mistakes, misinterpret policy language, or act unfairly.

This page is dedicated to guiding you through the process of appealing a denied disability insurance claim, whether it's a group or individual policy. We will explain why appeals are important, what steps to take, and how Dorian Law, with its combination of Deep Industry Knowledge, Proven Track Record of Success, and Our Client-Focused Approach, can significantly increase your chances of overturning a wrongful denial.

Why Choose Dorian Law for Your LTD Appeal?

Some people can submit a good long term disability appeal on their own. Others know that seeking experienced legal assistance from Dorian Law can significantly increase the chances of a successful outcome. This is especially true when:

  • Submitting an effective appeal requires strategic planning, specialized legal knowledge, and persuasive advocacy. At Dorian law our combination of client focus, proven success, and deep industry knowledge allows us to provide you with compassionate but effective representation and fight tirelessly for the disability benefits you deserve.

  • If the denial involves intricate medical records, vocational assessments, or policy interpretation complexities, our Proven Track Record in handling complex disability disputes is a significant advantage.

  • ERISA appeals are complex and have rigid requirements. Our Deep Industry Knowledge and ERISA expertise are invaluable in navigating this process and building a strong administrative record.

  • Dealing with a disability and a claim denial is emotionally and physically taxing. Our Client-Focused Approach means we can shoulder the burden of the appeal process, providing compassionate support and superb legal representation.

  • While ethical considerations prevent us from publishing specific case details, the testimonials and positive feedback we’ve received over the years from grateful clients are an undeniable testament to our Proven Track Record. Check out Dorian Law’s Testimonials page, where you will find quotes clients posted on public websites like Yelp, Google, and Avvo. Our clients’ satisfaction and the positive impact we’ve had on their lives are the ultimate measure of our success.

Don't let a wrongful disability denial derail your financial security. Let Dorian Law champion your appeal. Contact us for a free consultation to discuss your denied claim and learn how we can help you submit a powerful and effective appeal.

Why Appeal a Denied Disability Insurance Claim?

A well-prepared appeal provides you with the opportunity to:

  • Correct Errors: Point out errors in the insurance company's evaluation of your medical records, vocational assessment, or policy interpretation.

  • Provide New or Missing Information: Submit additional medical documentation, test results, physician opinions, or other evidence that strengthens your claim and addresses the reasons for denial.

  • Strengthen Your Case: Present compelling legal arguments and policy interpretations that demonstrate why you meet the policy's definition of disability and are entitled to benefits. This is where Our Deep Industry Knowledge of disability policy language and relevant case law becomes invaluable.

  • Preserve Your Legal Rights: For ERISA-governed group disability policies, exhausting the administrative appeal process is mandatory before you can file a lawsuit in federal court. For individual policies, a strong appeal can sometimes resolve the issue without litigation, or significantly strengthen your position if litigation becomes necessary. Our Proven Track Record includes successfully resolving disability claim denials at the appeal stage.

Understanding the Reason for Denial: Your Starting Point

The most crucial first step in preparing a disability appeal is to carefully review the denial letter you received from the insurance company. This letter must explain the specific reasons for the denial. Common reasons for disability claim denials include:

  • Insufficient Medical Evidence or Lack of "Objective" Findings

  • Failure to Meet the Policy's Definition of Disability

  • "Pre-Existing Condition" Exclusions

  • Independent Medical Examination (IME) Findings Contradicting Your Claim

  • Surveillance Evidence Contradicting Your Claim

  • "Change in Definition of Disability" Terminations (in LTD policies usually after 24 months)

  • Mental Health or Self-Reported Symptom Limitations

Once you understand the stated reasons for denial, you can tailor your appeal to directly address those specific issues.

Is Your Policy Governed by ERISA or State Law?

This Matters for Your Appeal Process

ERISA-Governed Policies (Group Policies through employers)

ERISA dictates a very specific administrative appeal process. You must exhaust this internal appeal process within the insurance company before you can file a lawsuit in federal court. ERISA appeals are typically decided based on the "administrative record" – the information presented during the appeal. It’s harder to introduce new evidence later in court. Because ERISA appeals have strict deadlines and procedural requirements, give strong consideration to obtaining experienced legal counsel.

Individual Policies (Purchased Directly or via non-employer groups)

Appeals for individual disability policies are governed by state insurance laws. The process is less rigid than ERISA. While there may not be a mandatory "administrative appeal" in the ERISA sense, you can still submit a formal appeal or request for reconsideration to the insurance company. This can be a valuable step in attempting to resolve the issue without litigation and building a strong case.

Submitting an Effective ERISA Disability Appeal

If your disability policy is ERISA-governed (likely if it is a group policy through your employer), your appeal process is strictly regulated by federal law. Here’s what you need to know to submit an effective ERISA appeal:

  • Deadlines are Crucial: ERISA sets strict deadlines for filing your initial appeal. Missing these deadlines can be fatal to your claim. Act promptly! The denial letter must state the appeal deadline, but no less than 180 days.

  • Focus on Building a Strong Administrative Record: Under ERISA, the court's review of a claim denial is generally limited to the "administrative record." This means your appeal is your primary opportunity to present all evidence and arguments supporting your claim. Gather everything upfront and submit it to the insurance company. If needed, ask for extensions of the appeal deadline so that you can build the strongest appeal possible. If you feel you might not be up to do the meticulous preparation needed to develop a strong administrative record, seek the help of experienced legal counsel.

  • Demand All Plan Documents and Relevant Information: Formally request, in writing, all plan documents from the plan administrator (usually the employer). Do the same for the insurance company, but ask for the claim file, procedures, and any internal rules, guidelines, or protocols the insurer had available in evaluating your claim. ERISA requires them to provide these. Doing this ensures you know exactly why your claim was denied. Experienced counsel will know how to use this information to your advantage.

  • “Full and Fair Review”: ERISA requires insurance companies to conduct a "full and fair review" of your appeal. This means they must consider all evidence you submit, provide you with access to relevant documents and information used in making their decision, ensure the appeal decision is made by someone independent of the initial denial, and explain the reasons for their decision in detail, referencing policy terms and evidence. It also means the appeal is not an adversarial process. Use this to your advantage - ask the insurance company to tell you exactly what they need to perfect your claim.

What to Include in Your ERISA Appeal

A successful ERISA disability appeal must be thorough and meticulously prepared. It should include:

  • A Detailed and Persuasive Appeal Letter: Clearly state you are appealing the denial. Identify the policy number, claimant name, and date of denial. Explicitly request a "full and fair review" under ERISA. Our Client-Focused Approach involves crafting strong and persuasive appeal letters on your behalf.

  • Directly and Thoroughly Rebut Each Denial Reason: Address each reason given for denial in the insurer’s letter, point by point. Explain why their reasoning is incorrect or unsupported by the medical evidence, vocational evidence, or policy language. Our Deep Industry Knowledge allows us to dissect denial letters, identify weaknesses in the insurer's rationale, and formulate targeted rebuttals.

  • Comprehensive Medical Evidence – Strengthen Your Record: Even if you submitted medical records with your initial claim, bolster your record for appeal. This might include:

    • Updated Medical Records: Current records reflecting ongoing treatment and status since the initial claim.

    • Detailed Physician Narrative Reports: Request your treating physicians to write detailed narrative reports specifically addressing the reasons for denial in the insurer's letter. The reports should clearly explain your diagnoses, symptoms, functional limitations, and why these limitations prevent you from performing the material duties of your occupation (or any occupation, depending on policy definition). Emphasize objective findings and the impact of subjective symptoms (like pain or fatigue) on your functional abilities.

    • Independent Medical Evaluations (IMEs) – Your Own (if necessary): If the insurer's denial relies heavily on an IME that contradicts your treating physician, consider obtaining your own independent medical evaluation from a specialist in the relevant field to provide a counter-opinion and strengthen your medical record.

    • Functional Capacity Evaluations (FCEs) and Vocational Assessments: If appropriate, submit updated FCEs or vocational evaluations that objectively assess your functional limitations and ability to perform work-related activities.

    • Neuropsychological Evaluations (NPEs): If a primary reason you are disabled is because of a reduction in your functional cognitive abilities, this battery of testing can offer objective evidence about how you are different than prior to your disability and why those changes are significant.

  • Vocational Evidence – Focus on Occupational Demands: In ERISA disability cases, vocational evidence is often critical. Include:

    • Detailed Job Description: Re-submit a detailed job description outlining the essential duties and physical/mental demands of your specific occupation (for "own occupation" policies) or a range of occupations (for "any occupation" policies).

    • Vocational Expert Opinion: Consider obtaining an opinion from a vocational expert who can analyze your medical limitations in relation to the demands of your occupation (or other occupations). A vocational expert can assess whether your functional limitations prevent you from performing your job duties or any reasonable occupation.

  • Legal Arguments and Policy Interpretation: If the denial involves policy interpretation issues, pre-existing condition exclusions, or other legal matters, present clear legal arguments and cite relevant ERISA case law supporting your position. Our Deep Industry Knowledge of ERISA law enables us to craft compelling legal arguments for your appeal.

  • Demand All Plan Documents and Information (Again): Re-request, in writing, all plan documents, summary plan descriptions, claims procedures, and any internal rules, guidelines, or protocols the insurer used in evaluating your claim and your appeal. ERISA mandates this "full and fair review" process requires them to provide these documents.

  • Maintain Professional Communication: Keep communication professional and respectful, even when frustrated. Focus on facts, evidence, and policy language in your appeal letter and all interactions with the insurer. Our Client-Focused Approach includes handling all insurer communications strategically and professionally on your behalf.

Submitting an Appeal for an Individual Disability Policy

For individual disability policies (state law governed), while the appeal process is less rigidly defined than ERISA, a well-prepared appeal is still crucial.

  • Review Your Policy and State Insurance Laws (Again): Check your policy for any stated appeal procedures. Also, research your state's insurance laws for any relevant regulations regarding disability claim appeals and "bad faith" protections.

  • Submit a Formal Appeal or Request for Reconsideration: Even if not strictly mandated, submitting a formal written appeal is highly recommended for individual policies. Treat this appeal as seriously as an ERISA appeal.

  • Elements of an Effective Appeal: While the ERISA "administrative record" framework is not directly applicable, the key elements of a strong appeal are very similar. Clearly state you are appealing the denial, referencing the policy provisions and facts that drive a positive outcome.

  • Directly and Thoroughly Rebut Each Denial Reason: Address each reason given for denial in the insurer’s letter, point by point. Explain why their reasoning is incorrect or unsupported by the medical evidence, vocational evidence, or policy language. Our Deep Industry Knowledge allows us to dissect denial letters, identify weaknesses in the insurer's rationale, and formulate targeted rebuttals.

  • Comprehensive Medical Evidence – Strengthen Your Record: Just like with an ERISA appeal, even if you submitted medical records with your initial claim, bolster your record for appeal. This might include:

    • Updated Medical Records: Current records reflecting ongoing treatment and status since the initial claim.

    • Detailed Physician Narrative Reports: Request your treating physicians to write detailed narrative reports specifically addressing the reasons for denial in the insurer's letter. The reports should clearly explain your diagnoses, symptoms, functional limitations, and why these limitations prevent you from performing the material duties of your occupation (or any occupation, depending on policy definition). Emphasize objective findings and the impact of subjective symptoms (like pain or fatigue) on your functional abilities.

    • Independent Medical Evaluations (IMEs) – Your Own (if necessary): If the insurer's denial relies heavily on an IME that contradicts your treating physician, consider obtaining your own independent medical evaluation from a specialist in the relevant field to provide a counter-opinion and strengthen your medical record.

    • Functional Capacity Evaluations (FCEs) and Vocational Assessments: If appropriate, submit updated FCEs or vocational evaluations that objectively assess your functional limitations and ability to perform work-related activities.

    • Neuropsychological Evaluations (NPEs): If a primary reason you are disabled is because of a reduction in your functional cognitive abilities, this battery of testing can offer objective evidence about how you are different than prior to your disability and why those changes are significant.

  • Vocational Evidence – Focus on Occupational Demands: In ERISA disability cases, vocational evidence is often critical. This can also be true for non-ERISA cases because it is far more common to see “true” own occupation definitions of disability. This means disability is based on your ability to do your job, not how the occupation is performed nationally. Also, many individual policies take into consideration work hours, while group policies, including ERISA policies, usually limit the assessment to the ability to work 40 hours a week. Thus, consider including:

    • Detailed Job Description: Re-submit a detailed job description outlining the essential duties and physical/mental demands of your specific occupation (for "own occupation" policies) or a range of occupations (for "any occupation" policies).

    • Vocational Expert Opinion: Consider obtaining an opinion from a vocational expert who can analyze your medical limitations in relation to the demands of your occupation (or other occupations). A vocational expert can assess whether your functional limitations prevent you from performing your job duties or any reasonable occupation.

  • Legal Arguments and Policy Interpretation: If the denial involves policy interpretation issues, pre-existing condition exclusions, or other legal matters, present clear legal arguments and cite relevant case law supporting your position. Our Deep Industry Knowledge enables us to craft compelling legal arguments for your appeal.

  • Timeline: Individual policy appeals may have less strict timelines than ERISA. However, prompt action is always best. Check your policy and state law for any guidance on appeal deadlines, and follow up if you don't receive a response within a reasonable timeframe (e.g., 30-60 days). Our Proven Track Record includes efficient case management and proactive follow-up with insurers in all types of disability claims.

Frequently Asked Questions (FAQ) About Appealing a Denied Long Term Disability Claim

  • A: Depending on your preference, we work on an hourly basis or on a contingency fee basis for disability appeal cases. We will openly discuss the advantages of each so you can make an informed decision. For contingency cases, you typically don't pay attorney fees upfront. Our fee is a percentage of the benefits we recover for you.

  • A: We provide honest case assessments and will advise you on the likely strengths and challenges of your case. Of course, the chances of success on appeal depend on the specific facts of your case, the policy language, the applicable law (ERISA or state law), and the strength of your legal representation. We will give you straight answers in your free consultation. While no attorney can guarantee a win, Dorian Law's Proven Track Record and industry knowledge significantly increase your odds of a favorable outcome.

  • A: Thoroughly address each reason for denial provided by the insurance company in their denial letter. Provide specific evidence and arguments to refute each point. In most cases, strong medical evidence, particularly detailed physician narrative reports directly addressing the denial reasons, is paramount. However, specific testing or vocational evidence might be more important to your specific claim. Dorian Law has the experience and knowledge to craft targeted and persuasive appeals that directly counter the insurer's rationale.

  • A: Yes, and you absolutely should! Your appeal is your opportunity to strengthen your case. For ERISA appeals, building a robust administrative record is critical. Gather updated medical records, physician opinions, vocational evaluations, and any other evidence that supports your disability and refutes the denial reasons.

  • A: No. Having the support of your treatment providers is critical, but it does not guarantee you will win your LTD appeal. We have seen too many people submit LTD “appeals” that simply say “I appeal, my doctor says I am disabled.” This is ineffective.

  • A: If your ERISA appeal is denied, you have the right to file a lawsuit in federal court. For individual policies, if your appeal is unsuccessful, your next step is typically to file a lawsuit in state court or federal court, potentially including "bad faith" claims. Dorian Law is prepared to litigate effectively and efficiently on your behalf if your appeal is denied. This is where our Proven Track Record in disability litigation becomes crucial.