When a Long-Term Disability Claim Gets Denied

A denial letter from your long-term disability (LTD) insurer does not end your claim. You have the right to challenge it through your plan's appeal process, and many denials are overturned on appeal because the initial review was incomplete or the insurer misread the medical evidence. The specific steps depend on whether your plan is governed by ERISA (the Employee Retirement Income Security Act), which covers most employer-sponsored LTD policies.

The denial letter itself must explain why the insurer rejected your claim — usually that you do not meet the plan's definition of disability, that your condition is not supported by medical records, or that you did not follow the plan's procedures. That explanation is your roadmap for appeal. You will need to gather stronger medical evidence, clarify facts the insurer got wrong, or show that the insurer applied the wrong standard.

An attorney who handles LTD appeals can review your denial letter, assess whether the insurer made a legal error, and decide whether appeal or litigation is worth the cost. This matters because LTD cases turn on technical rules about burden of proof, what "disability" means under your specific plan language, and whether the insurer followed its own procedures.

Key Takeaways

  • ERISA plans have a two-step appeal process: first an internal appeal to the plan administrator, then federal court if the internal appeal fails.
  • Non-ERISA plans (common in some states and industries) may allow direct lawsuit without exhausting internal appeals first.
  • An attorney can cost $2,000 to $10,000 or more for an appeal, but many work on contingency for cases that go to court, meaning they take a percentage of any recovery instead of an upfront fee.
  • The strongest appeals include new medical evidence, informed testimony about your condition, or proof that the insurer ignored or misread the records you already submitted.
  • Timing matters: ERISA plans typically require you to file an internal appeal within 180 days of the denial, though some plans allow longer.

ERISA Plans and the Two-Step Appeal Process

If your LTD plan is sponsored by your employer and governed by ERISA, you must exhaust the plan's internal appeal before you can sue in federal court. This is a legal requirement, not optional. The first step is a written appeal to the plan administrator (usually your HR department or the benefits office), and you must include any new evidence — medical records, test results, letters from your doctor, or statements from people who know your condition.

The plan administrator has 45 days to respond (or up to 90 days if the case is complex). If they deny the appeal, you can then file a lawsuit in federal court under ERISA Section 502. At that point, an attorney becomes much more valuable, because federal court involves discovery, motion practice, and the rules of evidence. Many ERISA attorneys work on contingency for litigation, meaning they take a percentage of any judgment or settlement rather than charging hourly fees.

The standard of review in federal court depends on the plan language. Some plans give the insurer discretion to interpret the policy, which means the court will defer to the insurer's decision unless it is clearly wrong. Other plans do not grant discretion, which means the court reviews the insurer's decision more strictly. An attorney will know which standard applies to your plan and how it affects your chances.

Non-ERISA Plans and Direct Litigation

If your LTD plan is not governed by ERISA — because you are self-employed, work for a government agency, or your employer chose a non-ERISA arrangement — you may be able to sue directly in state court without exhausting internal appeals first. This varies by state law. Some states require you to appeal internally anyway; others do not. An attorney licensed in your state can tell you what your state requires.

Non-ERISA litigation is often faster and gives you more discovery rights than ERISA cases, but it also means you are suing under state contract law or bad-faith insurance law, which has different standards and damages. You may be able to recover not just the denied benefits but also attorney fees, interest, and in some cases punitive damages if the insurer acted in bad faith.

Finding and Evaluating an LTD Attorney

Look for an attorney who specializes in disability insurance appeals and litigation, not general personal injury or workers' compensation. The National Association of Disability Representatives (NADR) and the American Association for Justice both have directories of attorneys who handle these cases. You can also ask your state bar association for a referral to attorneys who practice disability insurance law.

When you call, ask whether they work on contingency for litigation (most do), what their contingency percentage is (typically 25 to 33 percent), and whether they charge for the appeal stage (some do, some do not). Ask how many ERISA or LTD cases they have handled and what their track record is. A good attorney will be honest about your chances and will not promise a particular outcome.

Some attorneys offer a free initial consultation to review your denial letter and tell you whether appeal or litigation makes sense. Use that conversation to understand what evidence is missing, what the insurer got wrong, and what it will cost to fight. If the denied amount is small or the case is weak, the attorney may advise you not to pursue it.

What Evidence Strengthens an Appeal

The most common reason denials are overturned is that the initial review was based on incomplete medical records. If your doctor has written more detailed notes, test results, or functional capacity evaluations since the denial, those go into the appeal. If you have seen a specialist or had new imaging or testing, that evidence is critical. The insurer must consider all medical evidence in the record; if they ignored something, that is grounds for reversal.

informed testimony also carries weight. If your treating physician will write a detailed letter explaining why you cannot work, or if you can obtain an independent medical evaluation from a specialist, that strengthens the appeal significantly. Some appeals benefit from a vocational informed's opinion that your condition prevents you from doing any work you are capable of doing, which addresses the insurer's argument that you could do a different job.

Proof that the insurer misread or misapplied the plan language also wins appeals. If the plan defines disability as the inability to perform the duties of your own occupation, but the insurer denied you based on whether you could do any occupation, that is a legal error. An attorney will spot these mistakes and frame them for the appeal.

The Cost of Appealing and When It Makes Sense

An internal appeal can be done without an attorney if you are organized and have strong medical evidence. The cost is mainly your time and the cost of obtaining medical records and new evaluations. If you go to federal court, attorney fees typically range from $2,000 to $10,000 or more, depending on how complex the case is and how much discovery is needed.

On contingency, you pay nothing upfront, but the attorney takes a percentage of any recovery. If you win $50,000 in back benefits and the attorney takes 30 percent, you receive $35,000. That is still more than you would have received if you did not appeal, but it is less than the full amount. Contingency arrangements make sense when the denied amount is large enough to justify the attorney's time and risk.

If the denied amount is small — say, a few thousand dollars — or if your medical evidence is weak, an attorney may advise you that the case is not worth pursuing. That is honest counsel. Some people choose to appeal anyway on principle, or because they believe the insurer acted wrongly even if the legal case is weak. That is your choice to make.

Frequently Asked Questions

Can I appeal a denial on my own without an attorney?

Yes. The internal appeal process does not require an attorney, and many people handle it themselves by gathering medical records and writing a clear letter explaining why they meet the plan's definition of disability. An attorney becomes more valuable if the appeal is denied and you are considering federal court, because litigation involves complex procedural and evidentiary rules.

How long do I have to appeal after the denial?

ERISA plans typically require an appeal within 180 days of the denial, though some allow longer. Check your denial letter for the important date. Non-ERISA plans may have different timelines depending on state law. Do not wait; file as soon as you have gathered your evidence.

What if I cannot afford an attorney?

Many disability attorneys work on contingency for litigation, meaning you pay nothing unless you win. Some legal aid organizations also handle disability cases, though they are often overbooked. Ask the attorney about contingency options and whether they will handle the appeal stage for a flat fee or hourly rate.

Does appealing delay my benefits if I win?

If you win on appeal or in court, you typically receive back benefits from the date of the original denial, plus interest in some cases. The appeal process takes time, but you are not losing money by appealing — you are trying to recover money the insurer wrongly withheld.

What if the insurer says my condition is not disabling because I can work from home?

That depends on your plan's definition of disability. Some plans define it as inability to perform your own occupation; others use an "any occupation" standard. If your plan says you must be unable to perform your own job, and you cannot do your job even from home, you may still meet the definition. An attorney can review your plan language and argue this in the appeal.