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How to Appeal a Disability Insurance Denial

Had your disability insurance claim denied? According to Social Security Administration data,62% of SSDI claims are denied at the initial stage. For private disability insurance, the appeal process is critical — especially under ERISA. This guide shows you how to fight back.

Key Statistics: Disability Insurance Denials

  • 62% initial denial rate — SSDI applications denied at first stage (SSA Statistics)
  • 51% approval at ALJ hearing — Appeals that succeed at Administrative Law Judge level (SSA 2023 Report)
  • 60-180 days — Typical ERISA appeal deadline after denial (DOL ERISA FAQs)
  • ERISA limits remedies — No jury trials, typically only unpaid benefits recoverable (DOL 2016 Regulations)

Critical: ERISA Appeal Deadline

For employer-sponsored disability insurance, you typically have only 60-180 days to file an administrative appeal. Missing this deadline can permanently bar your claim. Check your denial letter immediately for the exact deadline.

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ERISA vs. Non-ERISA Disability Claims

ERISA-Governed Plans

Most employer-sponsored disability insurance

  • • Must exhaust administrative appeals first
  • • Federal court only (no jury trials)
  • • Limited to unpaid benefits recovery
  • • Court reviews only the administrative record
  • • Strict appeal deadlines (60-180 days)

Non-ERISA Plans

Government, church, individual policies

  • • State court with jury trial option
  • • Bad faith damages may be available
  • • Can present new evidence at trial
  • • State insurance laws apply
  • • More flexible appeal process

Source: Department of Labor ERISA FAQs

Why Disability Insurance Claims Get Denied

Insufficient Medical Evidence

The insurer claims your medical records don't support total disability. Often requires functional capacity evaluations and detailed physician statements.

Definition of Disability Change

Many LTD policies change from "own occupation" to "any occupation" after 24 months. Insurers claim you can do some other job.

Pre-Existing Condition Exclusion

Conditions diagnosed before coverage began may be excluded. Look-back periods typically 3-12 months before policy start.

Mental Health/Substance Limitations

Many policies limit mental health and substance abuse claims to 24 months, even for severe conditions.

Surveillance and IME Reports

Insurers use private investigators and "independent" medical exams to challenge your disability. Prepare for scrutiny.

SSDI vs. Private Disability Insurance Appeals

StageSSDI Denial RateSSDI Approval Rate
Initial Application62%38%
Reconsideration84%16%
ALJ Hearing49%51%
Appeals Council99%1%

Source: SSA Annual Statistical Report 2023

Step-by-Step: How to Appeal a Disability Insurance Denial

1

Request the Complete Claim File

Under ERISA regulations, you have the right to receive copies of all documents the insurer relied on. Request the full administrative file immediately.

2

Consider Legal Representation

For ERISA claims, the administrative appeal is crucial because courts review only the administrative record. Many disability attorneys work on contingency. Consult an attorney immediately after denial.

3

Gather Comprehensive Medical Evidence

Collect treating physician statements, functional capacity evaluations (FCE), and specialist opinions. Document how your condition prevents you from performing your job duties specifically.

4

Address Every Denial Reason

Your appeal must specifically address each reason given in the denial letter. Provide evidence countering each point. This is your chance to build the strongest possible record.

5

Submit Before the Deadline

ERISA appeals typically must be filed within 60-180 days. Check your denial letter for the exact deadline. Missing it can permanently bar your claim.

Sample Disability Insurance Appeal Letter

[Your Name] [Address] [City, State ZIP] [Date] [Insurance Company Name] [Claims Appeals Department] [Address] Re: Appeal of Long-Term Disability Claim Denial Policy Number: [Policy Number] Claim Number: [Claim Number] Group Plan: [Employer Name] Denial Date: [Date] VIA CERTIFIED MAIL - RETURN RECEIPT REQUESTED Dear Appeals Committee: I am writing to formally appeal the denial of my long-term disability benefits. Your letter dated [date] denied my claim because [quote exact reason(s)]. I believe this denial should be overturned for the following reasons: MEDICAL EVIDENCE OF DISABILITY: • My diagnosis: [Diagnosis with ICD-10 codes] • Treating physicians: Dr. [Name], [Specialty] • Functional limitations: [Specific limitations that prevent work] • Objective findings: [Test results, imaging, etc.] RESPONSE TO DENIAL REASONS: [Address each denial reason specifically with evidence] WHY I CANNOT PERFORM MY OCCUPATION: • My job as [Job Title] requires [list essential functions] • My conditions prevent me from [specific tasks] because [reasons] • Attached functional capacity evaluation demonstrates [findings] ENCLOSED SUPPORTING DOCUMENTS: • Letter from Dr. [Treating Physician] dated [Date] • Functional Capacity Evaluation dated [Date] • Updated medical records from [Dates] • [Other supporting documentation] Pursuant to ERISA regulations, I request that you: 1. Reconsider this claim and approve disability benefits 2. Provide copies of any new evidence or rationale used in this review 3. Notify me of the decision within 45 days as required Sincerely, [Your Name] [Phone Number] [Email Address] cc: [Attorney Name, if represented]

Frequently Asked Questions: Disability Insurance Denials

What is ERISA and how does it affect my claim?

ERISA governs most employer-sponsored disability insurance. It requires you to exhaust administrative appeals before suing, limits you to federal court (no jury), and typically caps damages at unpaid benefits.

How long do I have to appeal?

For ERISA plans, typically 60-180 days from denial. Check your denial letter for the exact deadline. Missing this deadline can permanently bar your claim and any future lawsuit.

Should I get a lawyer for my disability denial?

Yes, especially for ERISA claims. The administrative appeal builds the record for any future litigation — courts typically only review what was submitted during the appeal. Many ERISA disability attorneys work on contingency.

What if my plan changes from "own occupation" to "any occupation"?

Many LTD policies change the disability definition after 24 months. Prepare by documenting functional limitations that prevent you from performing any occupation, not just your specific job.

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About This Guide

This guide is provided for educational purposes only and does not constitute legal advice. Disability insurance claims, especially under ERISA, are complex — strongly consider consulting with a disability insurance attorney.

Statistics cited are from publicly available sources including the SSA, Department of Labor, and ERISA regulations.