Many people assume that if their long-term disability (LTD) appeal is denied, they can simply take the insurance company to court and present all the evidence they didn’t get to include earlier.
Unfortunately, that’s not how it works under the law that governs most group LTD policies: ERISA, which is short for the Employee Retirement Income Security Act.
If your LTD claim is covered by ERISA—and most employer-sponsored plans are—then your administrative appeal is probably your only chance to submit new evidence. If your appeal is denied and you go to court, you may be limited to the evidence that was in the file when the insurer made its final decision.
That’s why it’s so important to take the appeals process seriously.
What Happens at the Appeal Stage?
Once your LTD claim is denied or terminated, you usually have 180 days to file an appeal. This is your opportunity to respond to the insurer’s reasoning and submit any additional evidence that supports your right to benefits.
During the appeal process, you may submit:
- Updated or missing medical records
- Detailed statements from your treating providers
- Functional Capacity Evaluations (FCEs), neurocognitive tests, or imaging studies
- Witness letters from coworkers, family, or friends
- Clarifications about your job duties or your limitations
- A written legal argument showing how your condition meets the policy’s definition of disability
You have the right to build the strongest possible case at this stage—but only at this stage.
What Happens If the Appeal Is Denied?
If your appeal is unsuccessful, the next step is usually a lawsuit in federal court. But this isn’t a lawsuit as most people think of it.
Under ERISA:
- There is no trial.
- The judge does not hear live testimony.
- You cannot introduce new evidence or documents.
- You cannot introduce new medical records, letters, or evaluations that are not already in the claim file—even if they would be helpful.
The court’s job is to review the insurer’s decision based solely on the administrative record—the documents that were in the file and before the adjudicator when the final denial was issued.
If something important was left out of the record during the appeal, it will not be considered by the court. That’s why the appeal is not just a speed bump on the road to trial—it’s the most important part of the process.
Why the Appeals Stage Is So Critical
Think of your appeal as your “day in court”—because in most ERISA disability cases, that’s exactly what it is.
The appeal is your only opportunity to:
- Explain why the insurer got it wrong
- Correct errors or omissions in the record
- Add new, persuasive medical evidence
- Dispute unfavorable internal reviews or independent medical evaluations
- Fill in any gaps in documentation or clarity
You must show, through solid documentation, that no reasonable person could have denied your claim. If you don’t do this on appeal, the court won’t give you a second chance.
How to Strengthen Your Appeal
To make the most of your appeal window, consider including the following:
- A detailed letter from your treating physician explaining your functional limitations and why you can’t work
- Recent diagnostic test results that support your diagnosis
- A Functional Capacity Evaluation (FCE) that shows physical limitations
- A neuropsychological evaluation, if cognitive problems are part of your condition
- Statements from people who know you—family, friends, former coworkers—about how your condition affects your daily life
- A thorough legal brief that challenges the insurer’s reasoning and supports your entitlement to benefits
This is not the time to be vague or minimal. You need to make your case as clear, compelling, and complete as possible.
How an Attorney Can Help
You don’t have to hire an attorney to file your appeal—but having one can make a significant difference.
An experienced LTD attorney can:
- Spot weaknesses in the insurer’s reasoning
- Identify missing documentation or red flags in your claim file
- Help you gather strong medical opinions from your doctors
- Push back against biased or incomplete medical reviews
- Prepare a persuasive appeal letter based on both the evidence and the law
They can also help make sure everything is filed properly—and on time—so that the administrative record is complete and ready if you have to go to court.
Final Thoughts: This May Be Your Only Shot
If your long-term disability appeal is denied, it can be very difficult to win your case in court—especially if the record is missing key information. That’s why your appeal isn’t just paperwork. It’s your best chance to prove your case.
Don’t treat it as a formality. Treat it as the most important part of the process.
If you’ve received a denial and aren’t sure what to include in your appeal—or if you want to make sure your case is as strong as possible—contact our office for a free case evaluation. We’re here to help you make the most of your one chance to submit evidence that could make your case. Call (888) 321-8131 to schedule your free case evaluation today.
