A long-term disability denial is not a medical judgment. It is a written decision, made from a file, citing a reason you are allowed to answer. Marc Whitehead & Associates works as a long-term disability denial lawyer for claimants nationwide whose benefits were refused, terminated, or quietly stopped.
The letter in front of you is doing two things at once. It is telling you no, and it is telling you exactly which argument the insurer thinks it can win. That second part is useful, because an appeal that answers the stated reason directly is a very different document from one that simply says the decision was wrong.
Denials arrive at three predictable moments: after the initial application, after a routine benefit review, and at the point where the policy’s definition of disability changes. Each one calls for a different response.
Send us the letter. Call +1 (800) 562-9830 for a free review, with no obligation.
What Does Your Denial Letter Actually Say?
Insurers use a small number of standard reasons, and each one has a standard counter. Reading the letter closely is the first real work of the appeal.
“You are not disabled as defined by the policy”
This is the most common line, and it is not a statement about your health. It means the insurer concluded that your documented limits do not prevent the specific work the policy names.
The response is functional, not diagnostic. What matters is measured capacity, sitting and standing tolerance, concentration, attendance reliability, and how that compares to the actual demands of your occupation as the policy defines it.
“Insufficient objective medical evidence”
Here the insurer says the file lacks measurable findings that confirm the limitation. It shows up constantly in claims for fibromyalgia, chronic fatigue syndrome, migraine disorders, long COVID disability, and chronic pain.
Whether a policy can require objective proof at all is worth checking, because not all of them can. Where it can, the answer is usually validated functional testing, longitudinal treatment records, and treating-provider narratives that state specific limits rather than repeating a diagnosis.
“Your condition no longer prevents you from working”
This appears on terminations rather than initial denials, and it usually follows one of three things: a file review by a physician who never examined you, an independent medical examination arranged by the insurer, or surveillance footage.
An independent medical examination, shortened to IME, is a single visit with a doctor the insurer selects and pays. Surveillance is video or photographs, sometimes paired with a review of public social media. Both produce snapshots. Both are answerable with context, treating records, and evidence of what the activity actually cost you afterward.
“You do not meet the any-occupation definition”
Many group policies pay for the first 24 months if you cannot perform your own job, then continue only if you cannot perform any job you are reasonably fitted for by education, training, and experience.
A large share of terminations land at that transition, and nothing about your health has to change for it to happen. The fight becomes vocational: which jobs the insurer says you could do, whether those jobs exist in a meaningful way, and whether they match your documented restrictions and your earning history.
“Pre-existing condition”
Group policies often decline claims that begin in the first year of coverage if the condition was treated during a look-back window before coverage started. The dispute is usually about whether the earlier treatment involved the same condition that disables you now.
“Failure to provide requested information”
Sometimes benefits stop without a medical dispute at all, because a proof-of-loss form or an updated physician statement was late. These are the most fixable denials, and also the ones claimants most often assume are hopeless.
For a free legal consultation with a Disability lawyer serving Nationwide, call (800) 562-9830
What Should You Do in the First Week After a Denial?
Five things, in roughly this order, and none of them require a decision about hiring anyone.
- Record both dates. The date on the letter and the date you received it. Your deadline runs from receipt, so do not throw away the envelope.
- Request the complete claim file in writing. For employer-sponsored plans it is free, and it includes the reports of the physicians who reviewed your file and any vocational materials the insurer relied on.
- Keep treating. Gaps in care during an appeal are routinely read as improvement, whatever the real reason for them.
- Tell your doctors what the letter said. A provider who knows the insurer questioned your sitting tolerance can chart that specifically.
- Sign nothing yet. No settlement, no release, no recorded statement before someone has read the policy.
Which rights do plans not volunteer?
Two, and both are worth naming precisely.
If the plan develops new evidence or a new rationale during the appeal, it generally must give it to you with time to respond before a final denial.
And its final decision must explain why it disagreed with your treating providers. The Department of Labor’s fact sheet on the disability claims rule sets out both, for claims filed on or after April 1, 2018.
Not sure what to ask for or how to phrase it? Call +1 (800) 562-9830 and we will walk through it.
Nationwide Denied LTD Insurance Claim Lawyer Near Me (800) 562-9830
How Long Do You Have to Appeal a Denied Claim?
If your policy came through an employer, you generally have at least 180 days from receipt of the denial. That minimum comes from the federal claims-procedure rule at 29 C.F.R. § 2560.503-1, and some plans allow longer.
If you bought the policy yourself, the deadline comes from the contract and from state law, and it is frequently shorter.
Six months sounds generous and rarely is. Requesting the claim file takes weeks. Scheduling functional testing takes weeks. Getting a detailed narrative from a busy physician takes weeks. Claimants who wait two months to start usually find the calendar tighter than they expected.
Missing the window generally ends the claim. Courts rarely hear an employer-plan case where the internal appeal was never completed. Our page on the 180-day ERISA appeal deadline covers how that clock works and what happens when the plan misses its own deadlines.
Is the Appeal Different From a Lawsuit?
Yes, and for employer-sponsored plans the order is not optional. You appeal to the plan first, and you normally cannot sue until that appeal is finished.
What happens to the evidence?
It freezes. In most federal courts a judge reviewing an employer-plan denial is limited to the administrative record, meaning the documents the plan had when it made its final decision.
That means no discovery, no witness testimony, and no chance to hand the judge a report you obtained afterward. The appeal is where the case is won or lost, and a lawsuit filed on a thin record is usually an argument about a file that cannot be improved.
Do individual policies work the same way?
No. State contract law normally allows a lawsuit without an internal appeal, and the case proceeds like ordinary civil litigation: written discovery, interrogatories, depositions, responses to summary judgment motions, and trial if it goes that far. Some states also allow additional remedies.
Which track you are on is one of the first questions worth answering.
What Happens to Your Income While the Appeal Is Pending?
Nothing good, which is the part nobody prepares for. An appeal can take several months even when everyone meets their deadlines, and benefits are generally not paid during it.
Two practical questions come up in almost every consultation.
Should you apply for Social Security while the appeal runs?
Usually yes, and many group policies require it. The definitions are different, so an approval does not decide the insurance claim, though it does carry weight. Since April 2018, a plan that disagrees with a Social Security determination generally has to explain why in writing.
Be clear-eyed about the amount. The Social Security Administration reports that disabled workers receive an average monthly benefit of roughly $1,582, and most group policies subtract that payment from the private benefit rather than adding to it.
What about a settlement offer?
Run the math before signing. Insurers sometimes propose a lump-sum buyout instead of continuing monthly payments, and those offers often arrive when a claimant is most financially stretched.
A buyout can be reasonable. It can also be worth a fraction of the remaining benefit stream. The value depends on your age, the maximum benefit period, the offsets, and the strength of the file.
If an offer is already on the table, that is a reason to have someone read the policy this week rather than next month.
Does the Insurer’s Identity Change Anything?
It changes the tactics you should expect. Carriers differ in how heavily they use file-review physicians, how they staff appeals, and which provisions they reach for when closing a file.
Knowing that a particular company tends to lean on an any-occupation transition, or on surveillance, or on a self-reported-symptoms limitation, shapes what evidence goes into the appeal. Our directory covering how your insurer handles denials has a page for each of the major carriers.
If you have decided you want representation rather than information, our long-term disability lawyer page explains how we work and what it costs.
Questions People Ask After a Denial
My benefits were paid for two years and then stopped. Is that still a denial?
Yes, and it carries the same appeal rights as an initial refusal. A termination is treated as an adverse benefit determination, which means the same deadline applies and the same disclosure obligations attach. Terminations at roughly the two-year mark are usually about a change in the policy definition rather than a change in your condition.
The letter says I can appeal. Should I just use their form?
Most plans accept a written appeal with exhibits, and a form is rarely the strongest vehicle. What matters is that the submission arrives inside the window, identifies itself as an appeal, and answers the specific reason the letter gave. A one-page form usually cannot do the third thing.
Can I appeal twice?
Sometimes. Some plans have two levels, and whether the second is mandatory or voluntary is written in the plan document. A voluntary level cannot be required before you sue. Reading that language before you decide is worth the time, because guessing wrong can cost either months or the claim itself.
Will appealing make the insurer look harder at me?
Claim reviews and surveillance happen whether or not you appeal, so declining to appeal buys nothing. The realistic consideration is not whether to respond but how carefully, because everything you submit becomes part of a permanent record a court may later read.
A Letter Is Only One Side of the File
Marc Whitehead,
Houston Disability Attorney
Nobody reads a summary plan description while they are healthy. Then a claim goes in, a letter comes back, and suddenly a federal statute you have never heard of is deciding what happens to your income.
Those rules are unforgiving, but they are also knowable. There is a deadline that can be met, a file that can be requested, a record that can be built, and a set of disclosure obligations the plan owes you whether it volunteers them or not.
We would rather look at your denial letter early than clean up a closed record later. The review costs nothing and takes one conversation.
Marc Whitehead & Associates, +1 (800) 562-9830. Send the letter and the plan documents, and we will tell you where you stand.
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Houston, TX 77007
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