Why You Might Lose Your Long-Term Disability Claim Even If You Are Disabled

You’ve been diagnosed with a serious medical condition. You can’t work. You’ve done everything the insurance company asked—filled out forms, submitted medical records, and followed your doctor’s orders. Still, your long-term disability (LTD) claim was denied.

It feels like a punch to the gut. And unfortunately, it’s a situation many people face, especially those with employer-sponsored LTD policies governed by ERISA (the Employee Retirement Income Security Act).

So how is it possible to be truly disabled and still lose your LTD claim? The answer often comes down to technicalities, missteps, and the built-in advantages that insurance companies have in the claims process.

Here are some of the most common reasons why valid LTD claims are denied—and what you can do about it.

1. Insufficient Medical Evidence

You might feel that your condition speaks for itself, but insurance companies want clear, ongoing, and objective proof of your disability. If your medical records don’t fully document the severity of your symptoms or limitations, your claim could be denied.

It can be especially hard to prove conditions like chronic fatigue, fibromyalgia, or mental health disorders, even though these conditions are very real, without consistent documentation, testing, and specialist evaluations.

Tip: Make sure your doctor’s notes clearly outline how your condition limits your ability to work. Vague statements like “patient is doing okay” or “follow-up in 3 months” can be misinterpreted by insurance companies.

2. Your Doctor Didn’t Provide Enough Support

It’s not just about having a diagnosis, it’s about how your doctor communicates your limitations. If your physician doesn’t complete the insurer’s forms thoroughly or fails to connect your symptoms to specific work restrictions, it can destroy your claim.

Some doctors are also reluctant to get involved with insurance paperwork or legal matters, which can leave your claim unsupported. Our free Doctors Guide to ERISA explains why your doctor has nothing to worry about.

Tip: Ask your doctor to be specific about your physical and cognitive limitations. Functional capacity evaluations (FCEs) or narrative reports can be very helpful if done correctly.

3. Surveillance or Social Media Evidence

Insurance companies sometimes hire private investigators to conduct surveillance or monitor your social media. If you’re seen doing something that appears inconsistent with your claimed limitations, even if it’s just a “good day,” they may use that to deny your claim.

Tip: Be mindful of what you share publicly and understand that even routine activities can be taken out of context.

4. Missed Deadlines or Incomplete Paperwork

ERISA claims are filled with strict deadlines and complex procedures. Missing a deadline for submitting documentation or appealing a denial can be fatal to your claim—even if you’re clearly disabled.

Tip: Keep track of all correspondence from the insurance company and respond quickly. If you receive a denial, act fast—typically you have 180 days to appeal.

5. Your Policy’s Definition of Disability Changed

Many LTD policies define “disability” differently over time. For example, for the first 24 months, you may only need to show you can’t do your own occupation. After that, you must prove you can’t do any occupation. This is a much tougher standard.

Some claimants are caught off guard when benefits stop after this transition period.

Tip: Review your policy carefully to understand how “disability” is defined and prepare well in advance for the “any occupation” test.

6. The Insurance Company Had Its Own Doctors Review Your Case

Insurers often rely on in-house medical reviewers or third-party consultants to evaluate your claim. These doctors usually don’t meet with you; they only look at your paperwork. Your health is judged by someone who reads your file but never actually talks to you or sees how you’re doing in real life. Unsurprisingly, these reviews often favor the insurance company.

Tip: You can submit additional medical evaluations or rebuttal reports to challenge these reviews.

7. You Tried to Navigate the System Alone

ERISA claims can be especially challenging because the law puts strict limits on your rights. Many claimants lose simply because they didn’t know what evidence to include—or how to effectively counter the insurer’s reasoning.

Tip: If your claim is denied, consider hiring an attorney who understands ERISA and can help you build the strongest possible appeal.

Why the Insurance Company Has the Upper Hand

Even if you file a lawsuit after a denial, the odds can still be stacked against you. That’s because ERISA gives insurance companies significant legal advantages:

• Limited Court Review: In most cases, the court only reviews the administrative record—everything that was submitted before the final denial. You usually can’t add new evidence.
• Discretionary Standard of Review: If the plan gives the insurer discretionary authority, the court must defer to the insurer’s decision unless it was clearly unfair or biased. This means the insurer doesn’t have to prove they were right, just that they had some reasonable basis for denying the claim.
• No Jury Trial: ERISA cases are decided by a judge, not a jury, and there are no emotional appeals or punitive damages.

As a result, the same reasons an insurer uses to deny your claim, like vague medical notes, missing forms, or an unfavorable internal medical review, can be enough to hold up in court. That’s why building a strong appeal during the administrative process is so critical.

Moving Forward After a Denial

Losing a long-term disability claim doesn’t necessarily mean you aren’t disabled. Often, it means the insurance company didn’t see the evidence they were looking for—or chose to interpret the facts in their favor.

If you’re facing a denial, don’t give up. You may have the right to appeal and present additional evidence. But your next steps are crucial, especially under ERISA rules, where one misstep can cost you the benefits you’ve earned.

Need Help with a Denied Long-Term Disability Claim?

Ortiz Law Firm helps individuals who’ve been wrongfully denied long-term disability benefits. If your claim has been denied, we’re here to review your case and discuss your options—no pressure, just honest guidance. Contact us online or call (888) 321-8131 today to learn more.