When long-term disability (LTD) benefits are denied or terminated, the next steps are time-sensitive and technical—especially for policies governed by ERISA. A seasoned long-term disability attorney helps you build the administrative appeal with the right medical and vocational evidence, protect your rights under federal regulations, and pursue benefit reinstatement or litigation if needed. This guide explains the ERISA appeals process, common pitfalls, and how to position your claim for success.
What Is ERISA and Does It Apply to You?
The Employee Retirement Income Security Act (ERISA) is a federal law that covers most employer-sponsored LTD plans. It sets strict rules for timelines, evidence, and review. Individual disability policies you purchased yourself are usually not governed by ERISA and follow state law instead. Some plans—such as government or certain church plans—may be exempt. If your coverage came through your employer, there’s a strong chance ERISA applies.
Why LTD Claims Get Denied or Terminated
Insurers often deny initial claims or cut off benefits after paying for months or years. Common reasons include:
- Insufficient “objective” medical evidence
- Gaps in treatment or non-compliance with care
- Transitions from “own occupation” to “any occupation”
- Surveillance or social media contradicting reported limitations
- Paper-only “independent” medical reviews (no exam)
- Vocational assessments claiming you can do other jobs
- Mental/nervous condition time limits
- Pre-existing condition exclusions or policy limitations
ERISA Deadlines and Process: What You Must Know
ERISA requires a structured, time-bound process. If your claim is denied or benefits stop, you typically have up to 180 days to submit a written administrative appeal. Missing this deadline can permanently bar your rights. During the appeal, you’re entitled to request your complete claim file and plan documents and to add new evidence to the record.
The insurer must issue a decision within specific timeframes (often 45 days, with limited extensions). Critically, federal courts usually limit their review to the evidence in the administrative record at the time of the final denial. That means your appeal is your best—and sometimes only—chance to submit comprehensive medical and vocational proof. The plan’s wording can also affect the legal standard of review (for example, “abuse of discretion” versus “de novo”).
Building a Persuasive ERISA Appeal
A successful appeal is strategic, evidence-driven, and organized. Focus on proving functional limitations, not just diagnoses.
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Medical documentation
- Detailed treating provider narratives tying symptoms to specific work limitations
- Longitudinal records showing consistent treatment and response
- Side effects from medications and their impact on attention, stamina, reliability
- Diagnostic imaging, lab tests, and specialty consults where applicable
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Functional evidence
- Residual Functional Capacity (RFC) assessments tailored to your condition
- Functional Capacity Evaluations (FCEs) by reputable, neutral providers
- Symptom logs for pain, fatigue, migraine frequency, flare patterns
- For cognitive issues: neuropsychological testing with validity measures
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Vocational evidence
- Accurate job description and physical/cognitive demands analysis
- Transferable Skills Analysis that realistically considers your limitations
- Independent vocational expert opinion rebutting “any occupation” assertions
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Consistency and corroboration
- Align treating provider opinions with clinical findings and daily-life function
- Address surveillance or social media directly; explain context and variability
- Include third-party statements (family, colleagues) describing functional impact
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Strategic framing
- Cite plan definitions (own vs. any occupation), applicable limitations, and how your evidence meets them
- Identify procedural errors (e.g., failure to share adverse medical opinions before final decision) and request corrective action
- Reference Social Security Disability (SSDI) awards if obtained; explain why SSA’s findings support LTD eligibility even with different standards
Package everything into a cohesive appeal letter that outlines the legal and factual basis for reinstatement and indexes your exhibits.
Benefit Reinstatement After Termination
When benefits are terminated—often at the “any occupation” changeover—reinstatement requires demonstrating you remain disabled under the plan’s stricter definition. Emphasize:
- Updated medical records and new evaluations since termination
- Targeted testing that answers the insurer’s claimed gaps (e.g., FCE, neuropsych)
- Vocational proof that identified jobs are not feasible given your actual restrictions
- Adherence to treatment, efforts at rehabilitation, and why work attempts failed
- A reasoned response to insurer surveillance or paper reviews
If the insurer relied on a file review, consider requesting an in-person independent exam by a truly neutral specialist and document the need for functional testing over cursory chart reviews.
If the Appeal Fails: Litigation Under ERISA
If your administrative appeal is denied, you may file suit in federal court. Key characteristics of ERISA litigation include:
- No jury trial; the judge reviews the administrative record
- Remedies usually include back benefits, reinstatement, interest, and possibly attorney’s fees—not punitive damages
- The standard of review depends on plan language and jurisdiction
- Success often turns on how well the administrative record was built during the appeal
This is why front-loading the record with strong medical and vocational evidence is crucial.
How a Long-Term Disability Attorney Helps
An experienced ERISA attorney can materially increase your odds of reinstatement by:
- Managing deadlines and requesting the complete claim file and plan documents
- Identifying plan definitions, offsets (e.g., SSDI), and limitations affecting your claim
- Coordinating RFC forms, FCEs, and neuropsych testing tailored to your impairments
- Drafting detailed provider letters that connect objective findings to functional limits
- Securing vocational expert opinions and rebutting flawed insurer job matches
- Addressing surveillance, social media, or paper-review inconsistencies head-on
- Preparing a comprehensive, indexed appeal that preserves issues for court
- Evaluating settlement options versus continued litigation
Most ERISA appeals are won or lost in the administrative phase; legal guidance is particularly valuable there.
FAQs
- When should I contact an LTD attorney?
Immediately after a denial/termination or when you sense increased scrutiny (requests for updates, surveillance hints, “any occupation” reviews). Early involvement ensures deadlines are met and evidence gaps are closed. - How do attorneys charge?
Many offer free consultations and contingency arrangements for litigation. For appeals, fee structures vary (flat, hourly, contingency, or hybrids). Ask about costs for exams and experts. - What if I already receive SSDI?
Provide the SSA decision and supporting medical file. While standards differ, insurers often credit SSA findings—especially when supported by objective testing and consistent treatment. - Is my plan definitely ERISA?
Most employer-sponsored plans are, but government and some church plans are exempt. Individually purchased policies follow state law. An attorney can verify coverage status quickly.
Next Steps If Your Benefits Were Denied or Terminated
- Request your complete claim file, plan, and summary plan description in writing.
- Calendar the appeal deadline—typically within 180 days.
- Continue consistent medical care and fill evidence gaps with targeted testing.
- Avoid casual social media posts and document day-to-day limitations.
- Consult a long-term disability attorney to design a focused, evidence-rich appeal.
Summary
ERISA LTD appeals are deadline-driven and hinge on the quality of the administrative record. Strengthen your case with precise medical, functional, and vocational proof, and address insurer rationales directly. An experienced long-term disability attorney can coordinate the strategy that drives benefit reinstatement and protects your rights. This article provides general information, not legal advice—consult counsel about your specific situation.
