People who are denied disability and can’t work will be affected financially in an immediate and significant way.

But even if their long term disability insurance claim was denied, there is still hope. An appeals process is in place to help them fight an unjust denial and receive their benefits.

Understanding the rights afforded to consumers and what they should do if they believe their disability insurance company has wrongfully denied them coverage is critical for recovering the compensation they might need to move on with their life.

How does disability insurance work?

When an injury or illness prevents a person from working, money can be tight due to this loss of income, and long term disability insurance is often what people rely on in this situation.

Long term disability (LTD) insurance benefits involve monthly payments to essentially offer a portion of what a person would have received from their paycheck, which can make a scary financial situation much more manageable.

LTD plans typically last for periods of two, five, or 10 years, and some even last until retirement age. Short-term disability insurance, by contrast, is intended for periods of about three to six months.

Long term disability benefits typically cover up to 60 percent of a person’s gross monthly income.

Disability insurance may be more necessary than most people expect, according to the Council for Disability Awareness. Indeed, about 64 percent of wage earners believe their risk of becoming disabled for at least three months is 2 percent or lower.

However, they actually face a 25 percent chance, according to the Council for Disability Awareness. The average disability claim lasts for just under three years.

Most employers provide group long term disability insurance as a benefit for their workers. This can be an affordable option compared to an expensive individual policy.

Consumers do need to be aware of some of the common limitations associated with most group LTD plans, however, particularly as they relate to how they define the term “disability.”

Some long term disability policies only provide benefits if a person is completely disabled from any gainful occupation, according to PolicyGenius. This means if an employee could still do different aspects of their job or another job, they might not be fully disabled.

Typically, a person will not be able to receive benefits under a policy until they satisfy the elimination or waiting period, which can last anywhere from 60 to 180 days after an injury before disability benefits begin.

While an insurer may deny an LTD insurance claim, a person can still go through the appeals process to have that denial overturned.

What causes an LTD disability claim to be denied?

There are many reasons that a disability claim may get denied, according to the U.S. Department of Labor.

In some cases, claimants may not be eligible for the benefits they have applied for. In other situations, the plan administrator may simply need more information in order to make a decision on LTD benefits.

Potential reasons why a long term disability claim may have been denied include, but are not limited to, the following:

• Not meeting the definition of “disabled” under the terms of the policy
• Having an excluded or preexisting condition
• Missing medical records
• Insufficient evidence of the disability
• Self-reported symptoms (rather than hard records)
• The insurance company’s doctors disagree with the physician
• A person being caught doing things their disability would prevent them from doing

There are valid reasons an insurance company may deny a claim. However, this does not mean a claim denial is always right or is necessarily the end of the road.

Even after having a claim denied, a person may be able to file an appeal and have their benefits granted.

What to do if long term disability insurance is denied

When an employee opts for disability insurance through their employer’s plan or private registration, they may later be shocked when their application for long term disability is denied.

However, not all hope is lost. There are steps you can take if your long term disability is denied — in fact, many people have to go through the denial process before their benefits are finally granted. It is through an established denial and appeal process, often involving more than one push back by the insured, that benefits are finally actualized.

All disability insurance policies allow for at least one, and sometimes two, administrative appeals to be filed if a person’s benefits are denied, according to The Street.

Many people receive their benefits after going through the appeals process rather than being granted benefits immediately.

The first step in this documentation process is carefully reading the letter in which the long term disability is denied. Generally, denial letters spell out the reasons behind the denial and tell the person how the appeal process works with their policy, according to WikiHow.

If the person can determine why benefits were denied, they may be more likely to have their request for appeal granted.

For example, if the person was denied long term disability insurance benefits because they did not provide enough documentation, they may want to submit more documents, such as useful medical records that may have been missing the first time or other evidence of the disability as part of the appeals process.

The next step is to immediately request — in writing — a claim file from the insurance company. A person also can add to this claim file request a request for a copy of their long-term disability policy. Copies of this and the claim file should be guaranteed free of charge under U.S. law.

Alternatively, an employee can also seek a copy from their company’s human resources department.

The next step in the process of an appeal is a thorough review of the claim file once it is received.

Medical information must be thorough and can complete and include physician notes, diagnostic results from lab work, MRIs, X-rays, and CT Scans. If there have been any surgeries or adjunct visits to emergency rooms, information from these must be included in the record.

After gathering all the necessary information to fill the gaps, it would be beneficial a to get a written opinion by a doctor who is willing to truly access the case in total. Consumers may have to shop around for a physician willing to give his or her time.

Appeals can be best argued with as many supporting documents as possible. This can include medical records, new medical opinions, letters from friends or family members, vocational expert opinions, personnel files, employer statements, pain journals, disability decisions from other agencies, and more. Any documentation that can help support the appeal could be crucial in swaying the plan administrator’s opinion.

Finally, consumers need to make sure they submit their appeal and all of their information within 180 days of receiving a denial notice.

Most long term disability policies provided by employers are subject to ERISA, the Employee Retirement Income Security Act, according to the U.S. Department of Labor. Because of ERISA standards, the denial letter will spell out deadlines that must be met in order for a person to register an appeal if their long-term disability is denied on the first try. It’s not a bad idea to get a calendar and mark it with the deadlines to be sure the appeal is filed on time.

Once an appeal is filed, it must be reviewed by someone new who has not yet looked over the case to ensure the initial decision is not considered at all by the new review.

Consumers may want to regularly follow up with their insurance company to check on the appeal and follow the company’s progress.

Plan administrators have 45 days to review an appeal but may take up to 90 days total if special circumstances apply. Once a decision is made, reviews must send consumers a final decision notice that includes a detailed explanation, reference to plan provisions, information about any additional appeals, explanation of rights, and other information.

If continuing to appeal the decision does not produce a favorable outcome, some consumers may want to consult with an attorney and take legal action against their insurer.

Can you file a lawsuit?

You should only turn to litigation over an LTD insurance claim denial after exhausting all available levels of administrative appeal.

Under the terms of ERISA, no new evidence can be added to a case after the appeals have been submitted in the event you end up pursuing litigation. Because of this, your appeal should include as much favorable evidence for your claim as possible.

You should include all relevant medical records, an opinion from your doctor on your health, possibly third-party reports, and any documents you think will strengthen your disability insurance lawsuit.

If your LTD insurance benefits are denied, you may face a confusing bureaucratic process ahead. An LTD insurance lawyer can help you determine how you can best strengthen your case. They can also help you determine what information you should put in your file for your appeals, and if you end up deciding to pursue litigation, they can help you file the strongest lawsuit possible should you end up filing a lawsuit to contest your denial of benefits.

While any lawsuit filed under ERISA has the potential to go to trial, many of these cases are actually resolved through a settlement before they make it all the way to the trial stage.

Get help with your long term disability insurance appeal

If an insurance company denied your long-term disability insurance claim within the past 180 days, a knowledgeable insurance attorney can help you appeal.

Learn More