A denial of short-term or long-term disability benefits does not always end your claim. If your disability coverage is provided through an employer-sponsored benefit plan, you may have the right to challenge the decision through an administrative appeal governed by the Employee Retirement Income Security Act of 1974 (ERISA).

The appeal stage is an important part of the claim process. It provides an opportunity to respond to the reasons for the denial, correct inaccurate information, and submit additional evidence supporting your inability to work.

Review the Denial Letter

Begin by carefully reviewing the denial letter from the insurance company or plan administrator. The letter should explain why the claim was denied, identify the plan provisions used to make the decision, and provide instructions for submitting an appeal.

Common reasons for denying an ERISA disability claim include:

  • Insufficient medical evidence
  • Missing or incomplete claim forms
  • Failure to satisfy the plan’s definition of disability
  • Disagreement with the opinions of treating physicians
  • Questions about your occupational duties
  • Policy limitations or exclusions
  • Surveillance or social media activity
  • Missed deadlines or procedural requirements

Your appeal should directly address each reason given for the denial.

Confirm the Appeal Deadline

ERISA appeals are subject to strict deadlines. The denial letter should state when the appeal must be received and where it must be submitted.

Record the deadline immediately. Do not assume that telephone calls, requests for documents, or informal discussions with the insurance company will extend the time available to appeal.

Request Your Claim File

You may request a copy of the claim file and relevant plan documents. The file may contain information that was used to evaluate your claim, including:

  • Medical records and physician statements
  • Reports from insurance company medical reviewers
  • Vocational assessments
  • Surveillance reports
  • Internal notes and correspondence
  • Employment and occupational information
  • Relevant plan provisions

Reviewing these materials may help identify missing evidence, factual errors, or conclusions that should be challenged.

Strengthen the Medical Evidence

An appeal should include medical evidence explaining how your condition affects your ability to perform your occupational duties. A diagnosis alone may not establish disability under the terms of the plan.

Helpful evidence may include updated treatment records, diagnostic test results, physician statements, functional capacity evaluations, medication side effects, and documentation of physical or cognitive limitations.

Treating providers should understand the duties of your occupation so they can explain why your symptoms and restrictions prevent you from performing those duties reliably.

Explain Your Occupational Limitations

Provide a clear description of your actual job responsibilities. Explain the physical, mental, and cognitive demands of the occupation and how your condition interferes with those demands.

Relevant limitations may include difficulty sitting, standing, walking, lifting, concentrating, remembering instructions, managing stress, maintaining productivity, or attending work consistently.

Submit a Complete Administrative Appeal

In many ERISA cases, a court’s review may be limited primarily to the evidence included in the administrative claim record. Evidence that was not submitted during the claim and appeal process may be difficult to introduce later.

For this reason, the appeal should be as complete as possible. It should respond to the insurer’s findings and include all available medical, occupational, vocational, and supporting evidence.

Continue Medical Treatment

Continue attending medical appointments and following reasonable treatment recommendations while the appeal is pending. Gaps in treatment may be used to question the seriousness of your condition.

If you are unable to follow a treatment recommendation because of cost, side effects, transportation problems, or another reason, discuss it with your healthcare provider and ask that the issue be documented.

Keep Detailed Records

Keep copies of your denial letter, appeal, medical records, forms, emails, and correspondence. Use a delivery method that provides confirmation when submitting important documents.

Detailed records can help establish what was submitted, when it was sent, and whether it was received before the deadline.

Getting Help With an ERISA Appeal

ERISA disability appeals can involve complicated policy language, medical evidence, procedural rules, and strict filing deadlines. An independent attorney familiar with ERISA disability matters can review the denial, examine the claim file, identify additional evidence, and help prepare a thorough administrative appeal.

Seeking assistance early may provide more time to develop the record and address the issues raised by the insurance company or plan administrator.

This website provides general educational information and helps visitors explore options for connecting with independent legal professionals. It does not provide legal advice or legal representation.