Long-Term Disability Denial: The ERISA Appeal Checklist and the 180-Day Deadline

Why long-term disability claims get denied

The appeal checklist

Work through these in order. Each item is here because denial letters and court opinions have turned on it.

• Request the complete claim file in writing

  Ask for all documents, records, and other information relevant to the claim: reviewer reports, vocational analyses, surveillance, call notes, the policy, and the plan documents. The plan must provide them free. Ask on day one; the 180 days keep running while you wait.

• Calendar the deadline from the day you received the letter

  Write down the receipt date, count 180 days, and aim to file at least two weeks early. If the letter states a shorter period, it is wrong for an ERISA disability plan; a longer one governs. Never rely on a phone promise of an extension.

• Pull the policy definitions that control your claim

  Own occupation versus any occupation and the date the definition changes, the elimination period, the pre-existing condition look-back, any mental-health or self-reported-symptom limit, the offsets, and the maximum benefit period. Quote them, and tie every exhibit to one.

• Get a treating-physician narrative, not a checkbox form

  Diagnosis, objective findings, specific functional restrictions (sitting, standing, lifting, concentration, attendance), expected duration, and a direct reply to each point in the insurer’s reviewer report. The plan must explain any disagreement with treating professionals, so make the disagreement concrete.

• Add objective testing

  Imaging, nerve conduction studies, neuropsychological testing, a functional capacity evaluation, whatever fits the condition. Paper reviewers lean on the absence of objective findings; fill that gap where medicine allows, and have your doctor explain where it does not.

• Commission vocational evidence

  A vocational expert’s report that takes your documented restrictions and shows why you cannot perform your own occupation as performed in the national economy or, after the definition changes, the occupations the insurer listed. Rebut its vocational analysis job by job.

• Keep a symptom and activity diary

  A dated log of pain levels, fatigue, medication effects, missed activities, and bad days, in your own words. It answers surveillance that shows one good hour and gives your doctors specifics to cite.

• Get the employer’s job description and a supervisor statement

  The insurer’s occupational analysis may describe a generic version of your job. The real description, plus a supervisor or co-worker statement about physical and cognitive demands, pace, and attendance, ties your restrictions to actual duties.

• Answer every stated reason, and the Social Security award if you have one

  Respond to each reason in the denial letter with evidence and a policy citation. If Social Security found you disabled, include the award and the SSA file; the plan must explain any disagreement with that determination, and it usually urged you to apply because the policy offsets the payments.

• Send it trackable, keep everything, and confirm receipt

  Use a delivery method that produces a dated record, keep a complete copy of the package as sent, and ask the plan in writing to confirm the appeal is complete and timely. The file you are building is the one a court will read.

If you can only do three, do the file request, the deadline, and the treating-physician narrative; everything else builds on them.

The ERISA appeal rules that decide the case

ERISA covers benefit plans established or maintained by private employers (29 U.S.C. 1003). It does not cover governmental plans, church plans, or a policy you bought on your own; those follow state law and often allow broader remedies. For a covered plan, the Department of Labor’s claims-procedure regulation sets these rules.

• 180 days to appeal

  A disability plan must give you at least 180 days after you receive the denial to appeal (paragraphs (h)(3)(i) and (h)(4)). Miss it and the claim is usually over for failure to exhaust the plan’s remedies. Count from the day you received the letter, and file early.

• The insurer’s decision clock

  An initial disability claim must be decided within 45 days, extendable by two 30-day periods for reasons beyond the plan’s control (paragraph (f)(3)). An appeal must be decided within 45 days, extendable once by 45 days (paragraph (i)(3)). Silence past those deadlines violates the regulation.

• The claim file is yours, free of charge

  On request, the plan must provide reasonable access to, and copies of, all documents, records, and other information relevant to the claim at no cost (paragraph (h)(2)(iii)): reviewer reports, the vocational analysis, surveillance, internal notes. Request it before you write a word.

• Full and fair review of everything you send

  The appeal must take into account all information you submit, whether or not it was considered initially, without deference to the first decision, by someone who neither made it nor reports to the person who did (paragraphs (h)(2)(iv) and (h)(3)(ii)). Medical judgments require consulting a qualified health professional not involved the first time (paragraph (h)(3)(iii)).

• New evidence must be shown to you first

  For disability claims, the plan must give you, free and in advance, any new evidence or rationale it considers or generates on appeal, early enough for you to respond before the decision is due (paragraph (h)(4)(i)).

• The record then closes

  After the final decision, the administrative record is generally what a court reviews. Most federal courts confine ERISA benefit cases to the file the plan had when it decided, though practice varies by circuit and standard of review. Treat the appeal as the trial.

• Exhaustion, then court, under a standard of review

  You must complete the plan’s mandatory appeals, capped at two (paragraph (c)(2)), before suing under 29 U.S.C. 1132(a)(1)(B); if the plan failed to follow the regulation, the claim is deemed exhausted and denied without the exercise of discretion (paragraph (l)(2)). In court, the denial is reviewed de novo unless the plan grants the administrator discretion, in which case the question is abuse of discretion, with any conflict of interest weighed as a factor (Firestone Tire & Rubber Co. v. Bruch).

What an LTD appeal or lawsuit can recover

ERISA’s remedies are narrow by design. Knowing the list keeps you from chasing damages the statute does not offer, and points you to state law when it applies.

What the numbers look like

An LTD claim’s value is mostly arithmetic on the policy: the benefit percentage, the offsets, the months withheld, and the months left in the benefit period. The figures below are invented to show the shape.

• Start with the gross monthly benefit

  Group policies pay a fixed percentage of pre-disability earnings stated in the policy, up to a monthly cap. Check whether bonuses, commissions, and overtime sit inside the policy’s definition of earnings.

• Subtract the offsets

  Policies reduce the benefit by the other income they list, most often Social Security disability, workers’ compensation, state disability, and pensions. The net benefit is what the claim is worth per month.

• Count the months withheld

  From the first unpaid month to the decision or judgment. An appeal that uses the full regulatory clock plus a lawsuit can put years of benefits in dispute.

• Then count the months left

  The benefit period usually runs to a retirement age, or is often limited to 24 months for conditions the policy caps. Reinstatement is worth the remaining months times the net benefit, discounted for the definition-change risk.

If the appeal fails: five steps

1. 1

   Check whether a second appeal is required or voluntary

   A plan may require up to two appeals. A voluntary appeal beyond that cannot be held against you: the plan must waive any exhaustion defense and toll the limitations period while it is pending (paragraph (c)(3)). The final letter says which kind it offers.

2. 2

   Find the deadline to sue in the denial letter

   For disability claims, the final denial must state any contractual limitations period and the calendar date it expires (paragraph (j)(4)). The Supreme Court has enforced a plan’s own deadline to sue, even one that starts running before the appeal is over (Heimeshoff v. Hartford, 2013); if the letter omits the date, that omission is itself a violation worth raising.

3. 3

   File under section 502(a)(1)(B), in state or federal court

   The civil enforcement provision lets a participant sue to recover benefits due, enforce rights, or clarify future rights, and state and federal courts share jurisdiction over that claim (29 U.S.C. 1132(a)(1)(B) and (e)). These cases are commonly decided by a judge on the record rather than by a jury.

4. 4

   Know the standard of review before you value the case

   Under Firestone, review is de novo unless the plan grants discretion, in which case the court asks whether the denial was an abuse of discretion, weighing the insurer’s conflict of interest. Whether a discretionary clause is enforceable can depend on state insurance law; a lawyer will check both.

5. 5

   Read the denial letter’s appeal clause and quote it back in your appeal

   Every denial must describe the plan’s review procedure, its time limits, and your right to sue (paragraph (g)(1)(iv)). Quote that clause at the top of your appeal with the date you received the letter and the date the 180 days expire. If the plan then departs from its own stated procedure, you hold the record to argue deemed exhaustion (paragraph (l)(2)).