Disability Denial Case Value Calculator

ERISA vs. Individual Policy: The Critical Distinction

The type of policy you have controls almost everything — your deadlines, your evidence, and how much you can recover.

SSDI (Social Security Disability) is a separate federal system with its own application and appeal process, distinct from both of the above.

The Disability Appeal Process

1. 1

   Read the denial letter

   It states the reason and — critically — your appeal deadline, often 180 days for an ERISA plan.

2. 2

   Build the record

   Submit everything now: treating-physician statements, test results, functional-capacity evaluations, and vocational evidence. For ERISA, this is usually the only evidence a court will ever see.

3. 3

   File the internal appeal on time

   Missing an ERISA appeal deadline can forfeit your right to sue entirely.

4. 4

   File suit after exhausting appeals

   Once appeals are exhausted, you can sue — under ERISA in federal court, or under state law for an individual policy.

Why Claims Get Denied — and How to Fight Back

• “Insufficient objective evidence”

  Counter with objective testing, imaging, and detailed treating-physician opinions tying limitations to your condition.

• Paper reviews by insurer doctors

  Highlight that a hired reviewer who never examined you contradicts your treating providers.

• Surveillance / social media

  Insurers look for activity inconsistent with your claim — be aware of what’s observable.

• “Own occupation” vs “any occupation”

  Many policies tighten the definition of disability after 24 months; know which standard applies to you.

The Administrative Record Is Everything

In an ERISA case, you generally cannot introduce new evidence once you file suit — the judge reviews only what was in the file when the insurer made its final decision.