What to Do If Your Long-Term Disability Claim Is Denied Under ERISA

If your employer-provided long-term disability (LTD) claim is denied, you generally must file an internal appeal with the plan before you can sue, and for disability claims you get at least 180 days from the denial to do it. Treat that appeal as your main chance to win: get your claim file, answer every reason in the denial letter, and add the medical and vocational evidence the insurer said was missing. If the appeal fails, you can usually sue under ERISA to recover benefits.

Why LTD claims get denied

• “Not enough objective evidence”: the insurer says your records do not prove your limitations.
• Definition of disability not met: many policies first ask whether you can do your own occupation, then later switch to whether you can do any occupation suited to your training and experience.
• Paper reviews: an insurer-hired doctor who never examined you disagrees with your treating doctor.
• Surveillance or social media: a short video or photo is used to argue you can work full time.
• Pre-existing condition or plan exclusions, or gaps in treatment.
• Missed deadlines or missing forms.

Step 1: Read the denial letter closely

For disability claims, federal claims regulations require the denial notice to include:

• The specific reasons for the denial and the plan provisions relied on
• What additional information would help and why
• An explanation of why the plan disagreed with your treating providers, vocational experts or a Social Security disability decision
• Any internal rules or guidelines used, or a statement that none exist
• The appeal procedure, time limits and your right to sue, including any contractual deadline for filing a lawsuit and when it expires

Mark your calendar with the appeal deadline the day the letter arrives. Count from when you received it, and do not wait until the end.

Step 2: Get your claim file

Ask the plan or insurer in writing for your complete claim file, the full policy and plan documents, and every medical and vocational review. You are entitled to these free of charge. If the plan administrator ignores a written request for plan documents for 30 days, a court may impose a penalty of up to $110 a day (29 U.S.C. §1132(c)(1)).

Step 3: Build the appeal

The appeal must be decided by someone who did not make the first decision (and is not that person’s subordinate), with no deference to the denial. If medical judgment is involved, the reviewer must consult an appropriately qualified health care professional who was not involved in the first decision. Give that reviewer what the first one lacked:

• A detailed letter from your treating doctor that describes specific functional limits (how long you can sit, stand, lift, concentrate) and ties them to the policy’s definition of disability.
• Complete records: treatment notes, imaging, lab results, specialist evaluations and medication side effects.
• Functional capacity or neuropsychological testing where relevant.
• Vocational evidence explaining why you cannot do your occupation, or any occupation, given your limits.
• Your own statement and statements from family or coworkers describing a typical day.
• A Social Security disability award, if you have one; the plan must explain any disagreement with it.

If the insurer relies on new evidence or a new rationale during the appeal, it must give it to you free of charge and in time for you to respond before it decides. Respond in writing.

Example (hypothetical): Grace, a medical biller, stops working because of lupus flares. Her LTD claim is denied after a file review says she can do sedentary work. On appeal she submits her rheumatologist’s detailed limits on sitting and keyboard use, a functional capacity evaluation and a vocational report. The appeal now addresses the actual reason for the denial instead of repeating the original claim.

Deadlines at a glance

If the plan fails to follow these claims rules, you may be treated as having exhausted the appeal and can go straight to court, unless the violation was minor and harmless.

Surveillance, exams and social media

Insurers may hire investigators, review public posts or send you to an independent medical exam. Be consistent and accurate on every form and in every exam. Do not exaggerate or downplay symptoms, follow your treatment plan, and keep a simple daily log of symptoms and limits. Assume anything you post publicly may end up in the claim file.

Filing a lawsuit

After a final denial, ERISA §502(a)(1)(B) lets you sue to recover benefits due, enforce your rights under the plan and clarify your right to future benefits (29 U.S.C. §1132(a)(1)(B)). These claims can be filed in federal or state court. The court may award reasonable attorney’s fees and costs.

The standard of review is often the biggest issue. If a plan validly gives the insurer discretion, courts generally defer to its decision unless it was unreasonable. California Insurance Code §10110.6 voids discretionary clauses in life and disability insurance policies that cover California residents, so many California LTD cases are decided fresh by the judge. Self-funded plans not sold by an insurer may be treated differently.

For insured policies, you can also contact the California Department of Insurance for help or to file a complaint against the insurer.

Protect your job and other benefits

LTD replaces part of your income; it does not hold your job. California’s Fair Employment and Housing Act may require your employer to provide reasonable accommodation, which can include a leave of absence, and the California Family Rights Act may give you up to 12 weeks of job-protected leave if you are eligible. See reasonable accommodation, FMLA and CFRA leave and disability discrimination. Many LTD policies also reduce benefits by Social Security disability, State Disability Insurance or workers’ compensation payments, so read the offset section of your policy.

Frequently asked questions

Can I skip the appeal and sue right away?

Usually not. ERISA plans generally require the internal appeal first, unless the plan failed to follow the claims rules.

Should I submit new medical records on appeal even if I sent some before?

Yes. Send complete, updated records. In many cases the court looks mainly at the claim file, and adding evidence later can be difficult.

My Social Security claim was approved. Does that mean I win LTD?

Not automatically, because the definitions differ. But the plan must explain why it disagrees with a Social Security disability decision, and an award is strong evidence.

Is my government job’s disability plan covered by ERISA?

Generally no. Government and church plans are outside ERISA, and different rules and deadlines apply.

Can my employer fire me while I am on LTD?

LTD itself does not protect your job, but firing you because of a disability or a leave can violate FEHA or CFRA. Read more in our ERISA overview and get advice before signing any release.

Talk to a California employment lawyer

Employees First Labor Law represents workers exclusively. If your long-term disability claim was denied or your employer let you go while you were on disability, we offer free virtual consultations. Contact us or call (310) 853-3461.

This article is general information about California law as of 2026, not legal advice for your situation. Reading it does not create an attorney-client relationship.