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When a long-term disability (LTD) insurance company gathers new evidence against your claim while reviewing your appeal, you do not have to find out about it in a denial letter. A 2018 Department of Labor rule gives claimants the right to see that evidence first—and to respond to it before the insurer makes its decision.
What Is the 2018 Department of Labor Rule on LTD Appeals?
The Department of Labor’s 2018 rule requires insurance companies to disclose any new adverse evidence to a claimant during the appeal process before issuing a final determination. If the insurer plans to use that evidence to deny or uphold a denial of your claim, you must be given a meaningful opportunity to respond to it first.
This rule applies to employer-sponsored group disability plans governed by ERISA—which covers the vast majority of long-term disability policies offered through large and mid-sized employers. If your LTD coverage came through your job at a company like Verizon, Walmart, or a similar employer, your plan almost certainly falls under ERISA and this rule applies to you.
What Kind of New Evidence Might an Insurer Gather During an Appeal?
What is an Independent Medical Examination (IME)?
An Independent Medical Examination—commonly called an IME—is a medical evaluation the insurance company arranges with a physician of their choosing. The doctor reviews your medical records and may physically examine you, then issues a written report that the insurer can use to support its decision. Despite the word ‘independent,’ these physicians are hired and paid by the insurance company, which creates obvious incentive concerns.
If the insurer obtains an IME report during your appeal and intends to use it against you, the 2018 rule requires them to share that report with you before issuing a determination—not after. This gives you the opportunity to respond, challenge the doctor’s conclusions, or submit contradicting evidence from your own treating physicians.
What is a Peer Review Report (PRR)?
A peer review report is similar to an IME, but instead of examining you in person, the insurer’s physician reviews only your paper medical records and issues a written opinion. These reports are a frequent tool insurers use to dispute treating physicians’ conclusions without ever seeing the claimant directly.
Like IME reports, peer review reports must be disclosed to the claimant before a final appeal decision is made if the insurer intends to rely on them. In some cases, an insurer may commission both an IME and one or more peer review reports in the same appeal—each of which triggers the same disclosure obligation.
Received an IME or peer review report in your LTD appeal? Attorney Nick Ortiz knows how to challenge insurer-hired doctors. Call (888) 321-8131 for a free case evaluation.
How Should You Respond to Adverse Evidence During an LTD Appeal?
When an insurer discloses new adverse evidence, your response is not a formality—it is one of the most important steps in the entire appeal. A well-crafted response can attack the methodology, credentials, or conclusions of the insurer’s doctor and give the appeals reviewer concrete reasons to reject that report.
A strong response might include a rebuttal letter from your treating physician directly addressing the insurer’s doctor’s findings, supplemental medical records that contradict the report’s conclusions, or a vocational or functional capacity evaluation that undermines the insurer’s argument that you can return to work. An experienced LTD attorney can identify the specific weaknesses in these reports and build a targeted response.
Why Does the Right to Respond Matter so Much in ERISA Claims?
In most ERISA long-term disability cases, the administrative record is closed once the final appeal decision is issued. That means if you do not respond to adverse evidence during the appeal, you may lose your opportunity to counter it permanently—including in federal court.
The appeal process is already lengthy. A claimant typically has 180 days to submit an appeal, and the insurer then has up to 90 days—split across two 45-day review periods—to issue a decision. That timeline can stretch to six, seven, or eight months. The 2018 rule was designed to make that process fairer by preventing insurers from ambushing claimants with new negative evidence at the very end, when it is too late to fight back effectively.
The LTD appeal window is your best—and sometimes only—chance to fight back. Ortiz Law Firm helps claimants respond to insurer evidence and build winning appeals. Call (888) 321-8131 to get started.
Frequently Asked Questions
Does the DOL’s 2018 rule apply to all long-term disability claims?
The rule applies to ERISA-governed plans, which includes most employer-sponsored group LTD policies. Individual disability policies purchased directly—not through an employer—are generally governed by state insurance law rather than ERISA and may have different procedural protections. If you are unsure which rules apply to your plan, an LTD attorney can review your policy documents.
What happens if the insurance company does not disclose new evidence before denying my appeal?
Failing to disclose adverse evidence before issuing an appeal denial may violate the DOL’s claims procedure regulations. This procedural violation can be raised as an argument in federal court and may affect whether the court gives deference to the insurer’s decision. It is an important issue to flag with your attorney as early as possible.
Can I submit my own medical evidence in response to the insurer’s report?
Yes—and you should. A rebuttal from your treating physician is one of the most effective tools available. Your doctor can directly address the insurer’s report line by line, explain why the conclusions are unsupported, and reinforce the medical basis for your disability. This response becomes part of the administrative record and can be critical in any subsequent litigation.
How long do I have to respond to new evidence the insurer discloses?
The DOL rule requires that claimants receive enough time to respond before the final decision is issued. The specific timeframe can vary, but your insurer is obligated to give you a meaningful opportunity—not just a token few days. If the deadline seems unreasonably short, an attorney can help you request an extension or document the issue for the record.
Do I need an attorney to respond to an IME or peer review report?
You are not required to have an attorney, but these reports are specifically designed to undermine your claim, and responding to them effectively requires knowing how to identify flaws in methodology, credentials, and reasoning. An experienced LTD attorney can significantly strengthen your response and protect your rights throughout the appeal process.
Do not let the insurer’s hired doctors have the last word. Ortiz Law Firm fights back against IME and peer review reports in LTD appeals nationwide. Call (888) 321-8131 today.
