What happens when you appeal a long-term disability decision

When your long-term disability claim is denied or your benefits are reduced, you have the right to challenge that decision through your insurance company's appeal process. The appeal is a formal request asking the company to review their decision again, usually with new information or a different argument about why you meet the policy terms.

The steps and timelines for appeal depend on whether your long-term disability comes through your employer's group plan or a private policy you bought yourself. Employer plans are governed by federal law (ERISA), which sets strict important date and procedures. Private policies follow state insurance law, which varies by where you live. Both routes require you to submit written materials and follow the insurance company's specific process.

Most appeals take between 30 and 90 days to resolve, though some can stretch longer if the company requests medical records or a new examination. You do not automatically get a hearing or phone call — the company reviews documents you submit in writing.

Key Takeaways

  • ERISA plans (employer-sponsored) have strict appeal important date: you usually have 180 days from the denial letter to file, and the company must decide within 30 to 45 days.
  • Private disability policies follow state law, which sets different timelines — some states give you one year to appeal, others less — so check your policy and your state's rules.
  • Your appeal must include new medical evidence, clarification of how you meet the policy definition of disability, or documentation the company missed the first time.
  • If the company denies your appeal, you can file a complaint with your state insurance commissioner or, for ERISA plans, pursue a lawsuit in federal court.
  • Hiring a disability attorney or advocate before you appeal can improve your chances, especially if the denial involved a medical dispute.

Understanding the two types of long-term disability appeals

If your long-term disability comes through your employer, it is almost certainly an ERISA plan. ERISA (the Employee Retirement Income Security Act) is a federal law that governs employer-sponsored benefits. ERISA appeals follow a two-step process: an internal appeal within the insurance company, and then an external review if you lose the internal appeal. The company must make a decision on your internal appeal within 30 days if your case is straightforward, or 45 days if it requires more review.

If you bought a private disability policy on your own, your appeal follows your state's insurance laws. These vary significantly. Some states require the insurance company to respond within 30 days; others allow 60 or 90 days. Some states have an external review process similar to ERISA; others do not. Check your policy documents for the appeal timeline, or contact your state insurance commissioner's office to learn what your state requires.

The key difference: ERISA appeals have a federal safety net (you can sue in federal court if you lose), while private policy appeals end with your state insurance commissioner's complaint process. This makes the initial appeal more important in a private policy case.

What to include in your appeal letter

Your appeal must be in writing. The insurance company will have sent you a denial letter that explains why they denied your claim or reduced your benefits. Read that letter carefully — it tells you exactly what the company thinks you did not prove. Your appeal should address each reason they gave.

Start by restating your position clearly: "I am appealing the denial of my long-term disability claim dated [date] because I meet the definition of disability in my policy." Then organize your response by the company's stated reasons. If they said your medical records did not support your condition, attach new records from your doctor. If they said you could still work in some capacity, include a letter from your treating physician explaining why you cannot. If they said you did not follow the policy's requirements (like submitting forms on time), explain what happened and provide proof you did comply.

Include a cover letter that lists every document you are sending, so the company cannot claim something was missing. Number your pages. Keep copies of everything. If you are submitting medical records, ask your doctor's office to include a letter from the doctor specifically addressing the company's reason for denial — a generic medical record is less persuasive than a letter that says "This patient cannot work because [specific reason]."

Meeting ERISA appeal important date

For employer plans, the clock starts the day you receive the denial letter. You have 180 days to file your internal appeal. This sounds like a long time, but you should file much sooner — ideally within 30 to 60 days — because the company's decision on your appeal can take another 30 to 45 days. If you wait until day 170, you will not have time to pursue an external review if you lose.

Send your appeal by a method that creates proof of delivery: certified mail with return receipt, email with read receipt, or hand delivery with a signed receipt. Do not rely on regular mail. The company will tell you where to send it in the denial letter; if they do not, send it to the benefits administrator or claims department address on your policy documents.

After the company decides your internal appeal, if they deny it again, you have the right to an external review. This is a review by an independent reviewer outside the insurance company. You have 60 days from the internal appeal denial to request an external review. The external reviewer must decide within 72 hours for urgent cases or 30 days for standard cases.

Private policy appeals and state insurance rules

Private disability policies are regulated by your state, not by federal law. Your denial letter should tell you the appeal important date and process, but if it does not, contact your state insurance commissioner's office — they can tell you what your state requires and may have a form you can use.

Most states require the insurance company to respond to your appeal within 30 to 60 days. Some states have an independent external review process; others do not. If your state does not have external review, your next step after the company denies your appeal is to file a complaint with the state insurance commissioner. The commissioner's office can investigate whether the company violated state law, but they cannot force the company to pay your claim — they can only penalize the company or require them to follow the law going forward.

If the insurance commissioner's investigation does not resolve your case, you can hire an attorney and file a lawsuit in state court. This is more expensive and time-consuming than an appeal, but it is your option if the company wrongly denied your claim.

When to hire a disability attorney

You do not need an attorney to file an appeal, but an attorney can significantly improve your chances, especially if the denial involved a medical dispute or if the company ignored evidence you submitted. Many disability attorneys work on contingency, meaning they take a percentage of your back pay (usually 25 percent) only if you win, and you pay nothing upfront.

Consider hiring an attorney if: the company's denial letter contains factual errors or ignores medical evidence you submitted; your condition is complex or rare and requires informed explanation; the company is claiming you can work despite strong medical evidence you cannot; or you have already lost an internal appeal and are pursuing external review or a lawsuit.

You can find disability attorneys through your state bar association's referral service, through the National Organization of Social Security Claimants' Representatives (NOSSCR), or by searching "disability attorney" in your area. Many offer free initial consultations, so you can discuss your case before deciding whether to hire them.

What happens if your appeal is denied

If you have an ERISA plan and lose your internal appeal, you can request an external review. If you lose the external review, you can file a lawsuit in federal court. You have a limited time to do this — typically within three years of the denial, though the exact important date depends on your policy and your state. An attorney can tell you the specific important date for your case.

If you have a private policy and the company denies your appeal, you can file a complaint with your state insurance commissioner. The commissioner's office will investigate whether the company violated state law. If they find a violation, they can require the company to reconsider your claim or pay a penalty. If the commissioner's investigation does not help, you can hire an attorney and file a lawsuit in state court.

In either case, keep all documents related to your claim and appeal. You will need them if you pursue further action.

Frequently Asked Questions

Can I appeal if I missed the important date?

For ERISA plans, missing the 180-day important date usually means you lose your right to appeal, though there are rare exceptions if the company did not properly notify you of the important date. For private policies, the important date varies by state — some allow appeals up to one year after denial. Contact your state insurance commissioner to learn your state's rule, or consult an attorney when ready if you missed the important date.

Do I have to submit new medical evidence, or can I just ask them to reconsider?

straightforward asking them to reconsider rarely works. Your appeal should include new medical evidence, clarification of how you meet the policy definition, or documentation the company overlooked. If you have not seen a doctor recently, scheduling an appointment and getting an updated medical report strengthens your appeal significantly.

What if the company says they need more medical records?

If the company requests records during your appeal, provide them promptly — delays can reset the clock on their decision important date. Ask your doctor's office to send records directly to the company and request written confirmation of receipt. Keep a copy for your records.

Can I appeal if the company reduced my benefits instead of denying them completely?

Yes. A reduction in benefits is treated the same as a denial for appeal purposes. Follow the same process and timeline, and address in your appeal why the company's reason for the reduction does not explore to you.

What should I do while my appeal is pending?

Continue to comply with all policy requirements: submit medical records on time, report any work or income, and attend any medical examinations the company requests. Non-compliance can give the company a reason to deny your appeal. Keep records of everything you submit and when you submit it.