You paid into a policy for years so that this exact situation would be covered. Then the letter arrived and the answer was no. Marc Whitehead & Associates is a long-term disability lawyer team that represents claimants nationwide after an insurer denies, terminates, or underpays long-term disability benefits. We take the fight to the insurance company so you can put your attention back on your health.
Most people who call us are past the shock and into the practical questions. How long do I have? What did they actually deny? Is this worth challenging? Those questions have answers, and the answers depend on facts that are already sitting in your denial letter and your policy.
Talk it through with us. Call +1 (800) 562-9830 for a free case review.
Do You Need a Lawyer to Fight a Denied Disability Claim?
In most cases, yes, and the reason is procedural rather than emotional. If your policy came through your job, federal law usually limits a court to reviewing the written record built during your administrative appeal. Evidence you leave out now is evidence a judge will typically never see.
That single rule changes everything about how an appeal should be handled. The appeal is not a formality before the real case. In most employer-sponsored claims, the appeal is the case.
People generally benefit most from representation when the denial involves a serious or long-term condition, a benefit that was paid and then cut off, a settlement offer that is hard to evaluate, or a letter that cites reasons that do not match the medical file.
There is also a quieter reason. Insurance companies handle thousands of these files a year and know exactly what a persuasive appeal looks like. Claimants are doing it once, while unwell, on a deadline. That imbalance is the problem representation is meant to fix.
For a free legal consultation with a Disability lawyer serving Nationwide, call (800) 562-9830
Why Do Insurers Deny Claims That Look Valid?
Insurers rarely deny a claim by saying the condition is not real. They deny the paperwork. The denial usually rests on a gap in documentation, a definition inside the policy, or an opinion from a reviewer who never examined you.
What is an independent medical examination?
An independent medical examination, often shortened to IME, is a one-time exam by a physician the insurer selects and pays. It is not a treatment, and the doctor is not building a relationship with you.
An IME report often becomes the centerpiece of a denial. Our role is to compare that report against your treating records, your test results, and your actual work demands, and to document where it falls apart.
How does surveillance get used against a claim?
Insurers hire investigators to photograph or film claimants, and they also review public social media. A few minutes of footage can be presented as if it represents a typical day.
The counter is context. Someone with a spinal condition may be able to carry a grocery bag to the car and then be unable to move for two days. Medical records and daily-activity logs are what put a short clip back in proportion.
What does “insufficient objective evidence” actually mean?
It means the insurer says your file lacks measurable test results that confirm the limitation. It appears constantly in claims for fibromyalgia, chronic fatigue syndrome, migraines, long COVID, and chronic pain, where no single scan proves the condition.
Policies vary on whether objective proof can even be required. Where it can, the answer is usually functional evidence: validated testing, treating-provider narratives that describe specific limits, and consistent longitudinal records.
What happens when the policy switches to “any occupation”?
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 suited for. The definition changes, and a large share of terminations land right at that mark.
Nothing about your health has to change for benefits to stop. If your claim is approaching that transition, the vocational evidence in your file matters more than almost anything else. Our page on own-occupation disability claims explains how that definition works.
Can a pre-existing condition clause be used to deny a claim?
Yes, and it is one of the most common reasons an early claim gets rejected. Many group policies decline to pay if the disabling condition was treated during a look-back window, often the three to twelve months before coverage started, and if the claim begins within roughly the first year of coverage.
The fight is usually about characterization rather than dates. An insurer may treat a routine visit years ago as evidence of the same condition that disables you now. Where the two are medically distinct, treating-provider testimony and the actual chart notes are what separate them.
Nationwide Long Term Disability Lawyer Near Me (800) 562-9830
Is Your Policy Governed by ERISA or by State Law?
This is the first question we ask, because it decides your deadlines, your remedies, and where your case can be heard. Policies obtained through an employer are usually governed by a federal law called ERISA, the Employee Retirement Income Security Act. Policies you bought yourself are usually governed by state contract law.
| Employer-sponsored (ERISA) | Individual policy you purchased | |
|---|---|---|
| Governing law | Federal (ERISA) | State contract and insurance law |
| Appeal before suing | Typically required | Usually not required |
| Time to appeal a denial | At least 180 days (29 C.F.R. § 2560.503-1) | Set by the policy and state law |
| Evidence a court reviews | Usually only the administrative record | Normally open discovery |
| Jury | Generally not available | Often available |
| Recovery | Generally benefits owed, plus possible interest and fees | May include additional state-law remedies |
Getting this wrong at the start is expensive. A claimant who treats an ERISA claim like an ordinary insurance dispute can run out the appeal clock and lose the ability to sue at all. We go through this in detail on our page about ERISA disability claims.
Not sure which one you have? Send us the policy and the denial letter. Call +1 (800) 562-9830.
What Is the Deadline to Appeal a Denial?
Under the federal claims-procedure rule, an employer-sponsored disability plan must give you at least 180 days from receipt of the denial to file your appeal. That window comes from 29 C.F.R. § 2560.503-1, and some plans allow longer.
Individual policies are different. Their deadlines come from the contract itself and from state law, and they are frequently shorter.
Two things about that 180-day figure surprise people. It runs from the date on the letter, not from the day you decided to do something about it. And filing on day 179 is usually a poor strategy, because those months are the only chance you get to build the file.
Missing the deadline generally means the claim is over. Courts rarely hear an employer-plan claim where the internal appeal was never completed.
The Conditions We See Most Often
Long-term disability claims turn on function, not diagnosis. What matters is what the condition prevents you from doing, documented well enough that a stranger reading the file reaches the same conclusion your doctor did.
We regularly handle claims involving cancer and treatment side effects, cardiac and pulmonary disease, spinal and orthopedic conditions, autoimmune and neurological disease, chronic fatigue syndrome, fibromyalgia, migraine disorders, post-COVID conditions, and psychiatric conditions including depression, anxiety, and PTSD.
Claims built on self-reported symptoms draw the closest scrutiny, and they are also the ones where careful documentation changes outcomes most. You can see how a long-term disability claim works from application through appeal.
Combination claims deserve a note of their own. Many people are disabled by more than one condition at once, and insurers often evaluate each in isolation until none of them looks disabling by itself. The honest picture is usually cumulative, and it has to be documented that way.
Denied, terminated, or facing a benefit review? Call +1 (800) 562-9830.
The Insurers on the Other Side of These Claims
We handle claims against the carriers that write most group and individual disability coverage in the United States, including Unum, The Hartford, MetLife, Prudential, Lincoln Financial, The Standard, Cigna, Liberty Mutual, Sun Life, Aetna, Reliance Standard, and Mass Mutual.
Carriers differ in how they review files, how they use outside physicians, and how their appeals are staffed. Knowing what a particular company tends to do with a particular kind of claim shapes how the appeal gets written. Our directory of the insurers we take on covers each one.
What Can a Denied Claim Actually Recover?
The benefits themselves, in almost every case. What varies is whether anything else is available on top, and that depends on where your policy came from.
What does a successful claim actually pay?
The monthly benefit. That means the payments that were wrongly withheld, plus reinstatement going forward under the terms of the policy.
Depending on the law that applies, interest and attorney fees may also be available.
What does federal law leave out?
Damages beyond the benefits. For employer-sponsored claims, federal law generally confines the recovery to plan benefits and related relief.
It does not typically allow damages for emotional distress or punitive damages. Individually purchased policies are governed by state law instead, which sometimes opens the door to additional remedies.
Why is the monthly amount lower than expected?
Two reasons, and they compound. Group benefits are usually calculated as a percentage of pre-disability earnings rather than the full amount, and most policies then subtract other income such as Social Security disability, workers’ compensation, and some retirement payments.
For scale, the Social Security Administration reports that disabled workers receive an average monthly benefit of about $1,582, rarely enough on its own to replace a working income.
What if the insurer offers a lump sum instead?
Some claims end in a lump-sum buyout, where the insurer offers a single payment to close the file permanently.
A buyout can be reasonable. The value depends on your age, the remaining benefit period, the offsets, and the strength of the file, and those offers deserve careful math before anyone signs.
Building an Appeal Record That Holds Up
We start from the insurer’s own words. The denial letter states the reason the claim failed, and every piece of evidence we gather has to answer that reason directly. Generic medical records rarely move a claim; targeted evidence does.
Under the federal claims rule, you are entitled to the complete claim file free of charge, including the reports of the physicians who reviewed your file and the vocational materials the insurer relied on. That file usually reveals which conclusions were reached, by whom, and on what basis.
From there the work is building evidence the insurer did not have. That often includes functional capacity testing, treating-provider narratives that describe specific and measurable limits rather than a diagnosis, vocational evidence about the real demands of your occupation, and statements from people who see your daily function.
The rules also require the plan to give you any new evidence or new rationale it develops on appeal, in time for you to respond, and to explain in writing why it disagrees with your treating providers or with a Social Security disability determination. The Department of Labor’s fact sheet on the disability claims rule sets out those protections. They apply to claims filed on or after April 1, 2018, and they are frequently under-used.
What Does Working With This Firm Look Like?
It starts with a free review of your denial letter and your policy, and there is no obligation attached to it. Most long-term disability matters are handled on a contingency-fee basis, which means legal fees are paid out of what is recovered rather than out of your pocket.
From there the work is concrete. We request the complete claim file, which you are entitled to at no charge under the federal rule. We identify what the insurer relied on and what it ignored. We gather treating-provider evidence, functional testing, and vocational evidence tied to the exact policy definition at issue. Then we write the appeal to answer the stated reason for denial point by point.
If the appeal is denied, we evaluate litigation. Because we represent claimants nationwide, where your case is filed and which federal circuit’s law applies are part of that conversation from the beginning.
Long-Term Disability Questions People Ask Before Hiring a Lawyer
Can I switch lawyers if I already filed my appeal myself?
Often yes, though timing matters a great deal. If the appeal is still open, there may be room to supplement the record. If a final denial has already issued, the record may be closed and the options narrow to litigation. Send us what you have and we will tell you honestly what is still available.
What does it cost to hire a long-term disability attorney?
The consultation is free. These cases are typically taken on contingency, so the fee is a percentage of what is recovered and there is no hourly bill. We explain the fee arrangement in writing before you sign anything, including how any awarded attorney fees are handled.
Will my employer find out I hired a lawyer?
Your employer is not usually the decision-maker on the claim. The insurer or plan administrator handles it, and correspondence runs through us. Your employer may learn that a claim is in appeal because it sponsors the plan, but the legal representation itself is between you and this firm.
How long does a long-term disability appeal take?
For employer-sponsored plans, the federal rule generally gives the plan 45 days to decide an appeal, with one extension of up to 45 more days. Litigation, if it becomes necessary, adds considerably more time. We would rather give you a realistic range for your specific claim than a number that sounds good.
Do you handle claims outside of Texas?
Yes. Marc Whitehead & Associates represents disability claimants across the country. Long-term disability law is largely federal, so the applicable rules travel with the policy rather than with your address.
The Letter Is Not the Last Word
Marc Whitehead,
Houston Disability Attorney
An insurance company wrote three pages explaining why you do not qualify. Those three pages were written by someone who has never met you, working from a file they assembled themselves.
You are allowed to answer. You are entitled to the whole claim file, to submit new evidence, and to have a decision-maker who did not make the first call review it again. Most people never use those rights, which is exactly what makes them valuable.
Send us the denial letter and the policy. The review is free, the conversation is straightforward, and you will leave it knowing what your options actually are.
Call Marc Whitehead & Associates at +1 (800) 562-9830, or request your free case review online.
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Houston, TX 77007
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