At Hawks Quindel, S.C., our long-term disability attorneys help workers challenge denied LTD claims and build appeals that address the reasons benefits were refused. If you have a denial letter in hand, the next steps matter.
The insurer has explained why it believes you do not qualify, and you may have a limited period to challenge that decision. Do not assume that sending another copy of your medical records or a letter saying you disagree will be enough. An LTD appeal may require additional medical, occupational, and vocational evidence targeted to the specific weaknesses the insurer identified.
For many workers who have spent years or decades in the same career, disability benefits represent an important source of income when illness or injury makes continued work impossible. Our attorneys can review the denial, determine the applicable appeal process, and develop the evidence needed to pursue the claim.
Securing Disability Benefits Rightfully Owed to Wisconsin Workers
Why Was Your Long-Term Disability Claim Denied?
The denial letter should identify the insurer's reasons for refusing benefits and the policy provisions it relied upon. Understanding those reasons is the starting point for an effective appeal.
Common denial issues include:
- Insufficient medical evidence: The insurer argues that medical records do not document restrictions severe enough to prevent work.
- Disputed functional limitations: The insurer accepts that you have a diagnosis but contends that the condition does not prevent you from performing your occupational duties.
- Medical reviews or examinations: An insurer's reviewing physician or independent medical examiner reaches conclusions that differ from those of your treating providers.
- Surveillance or other investigation: The insurer uses observed activities, social media, or statements from the claim file to question your reported limitations.
- Policy definitions or exclusions: The insurer determines that your condition does not satisfy the policy's definition of disability or applies a limitation or exclusion.
- Own-occupation or any-occupation requirements: The insurer contends that you can still perform your own occupation or another occupation permitted by the policy.
An appeal should respond to the reason actually given. More medical records do not necessarily solve a vocational dispute, for example, and a general statement from a physician may not resolve questions about specific functional restrictions.
How Long Do You Have to Appeal an LTD Denial?
If your disability plan is governed by the Employee Retirement Income Security Act of 1974 (ERISA), you generally must receive at least 180 days after receiving an adverse benefit determination to file an appeal. Your Summary Plan Description and claims procedure should be checked because the plan may provide a longer period.
Your denial notice should also explain the appeal procedure and applicable time limits. That deadline should be treated seriously. ERISA generally requires claimants to complete the plan's internal claims process before pursuing a lawsuit for benefits. There are exceptions, including circumstances involving a plan's failure to establish or follow compliant claims procedures, but a claimant should not assume an exception will apply.
Waiting until the end of the appeal period can also make it harder to develop evidence. Medical providers may need time to respond, records may need to be obtained, and vocational or occupational issues may require additional investigation.
If you recently received an LTD denial, consider having the denial letter and policy reviewed before submitting your appeal. Our attorneys can identify the applicable deadline and determine what evidence may be needed to challenge the insurer's reasoning.
Why Is the Administrative Record So Important in an ERISA LTD Appeal?
An ERISA appeal is more than a request for the insurer to change its mind. It is an opportunity to develop the record in support of your claim.
The U.S. Department of Labor advises disability claimants to include the information and evidence they want the plan to consider before the appeal deadline. Claimants can also request relevant claim documents and information without charge and request the identity of medical or vocational experts whose advice the plan obtained. That makes the administrative appeal an important stage in evidence development.
Depending on the denial, the record may need medical records, treating provider opinions, test results, documentation of symptoms and side effects, descriptions of occupational duties, or vocational evidence. If an insurer relied on an examination, file review, or surveillance, the appeal may also need to address that evidence directly.
This matters because if the appeal remains unsuccessful and litigation follows, the administrative record can play a central role in the court's review. A claimant should not assume that missing evidence can simply be added later in litigation.
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I can’t praise Aaron Halstead and Connor Clegg enough for their work on my legal matter. I especially appreciated their thoroughness, patience, and insight. They were always responsive to my questions. They helped me navigate a challenging workplace issue and obtain a good outcome. I would and do recommend them.
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During this very difficult time, the staff at Hawks and Quindel kept me reassured and informed every step of the way. I had the pleasure of working with Attorneys Jessa Victor and Brook Tylka. Jessa, Brook, Matt, and Hadley, thank you for all of your hard work, professionalism and compassion!...
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From our first phone call with Donnie Malchow, we knew we'd found the right person to help us. I had filed for disability and been denied. He was willing to walk beside us and thoroughly explain the entire process (lasted over a year and a half) and expectations (gave us...
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Attorney Halstead and his team went above and beyond to not only win my case, but because of certain circumstances I had going on, they did everything they could to help and rush the settlement through. They were always quick at responding to emails and phone calls with questions I...
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Many thanks from my family to all of you at the firm!!! Hawks Quindel, S.C. is the only place I would consider for LTD, disability, SSDI, ERISA, EEOC, DRoW legal help!! Jessa Victor and her team got me all the answers and results when I didn't think it was possible!!!...
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Was Your Claim Denied Under an Own-Occupation or Any-Occupation Definition?
The definition of disability in your policy can determine what you need to prove. An own-occupation standard generally focuses on whether your condition prevents you from performing the material duties of your occupation. An insurer might accept that you have a significant medical condition but deny the claim because it believes you remain capable of performing those duties.
Some policies eventually apply an any-occupation standard. The question then changes to whether you can perform another occupation that satisfies the policy's requirements.
That transition can be particularly important for someone who has spent much of a career in one occupation. An insurer's conclusion that you can perform different work may raise questions involving your restrictions, education, training, work experience, transferable skills, occupational demands, and the policy's earnings requirements.
An effective appeal should address the standard the policy actually applies rather than treating disability as a purely medical question.
What Do Our LTD Attorneys Do After a Denial?
Our attorneys begin by determining why the claim was denied and what evidence the insurer considered. The goal is not to submit more paperwork for its own sake. It is to identify the weaknesses the insurer claims exist and develop a record that addresses them.
Depending on the circumstances, our attorneys can:
- Review the denial letter, policy, Summary Plan Description, and applicable deadlines.
- Request the insurer's claim file and other relevant claim materials.
- Analyze medical reviews, vocational assessments, surveillance, and other evidence used against the claim.
- Work to develop medical evidence that explains specific functional restrictions rather than relying only on diagnoses.
- Address occupational or vocational issues when the insurer argues that other work is possible.
- Prepare and submit the administrative appeal with supporting evidence and legal arguments.
The exact work depends on the denial. A claim involving chronic pain and physical restrictions may require different evidence than a claim involving cognitive impairment, progressive disease, or an insurer's assertion that someone with a long-established career can transition to another occupation.
Hawks Quindel, S.C., handles long-term disability matters, as well as Social Security Disability and workers’ compensation claims. That broader disability practice can be useful when multiple benefit systems affect the same worker.
Attorney Tim Maynard represents clients in disability matters and can help workers understand the issues involved in challenging an LTD denial. To learn more about your specific rights, reach out today.
What Happens If the LTD Appeal Is Also Denied?
If an ERISA plan denies the required administrative appeal, the next step may be a lawsuit seeking benefits under federal law. Department of Labor guidance states that, with limited exceptions, claimants normally must complete the plan's claims process before bringing an action in court.
Litigation is not simply another round of the administrative appeal. The applicable standard of judicial review can affect how a court evaluates the insurer's decision.
You may encounter the phrase “arbitrary and capricious” when researching ERISA litigation. In cases where that deferential standard applies, the court examines the plan administrator's decision under that standard rather than independently deciding the claim from scratch. The governing policy language, plan documents, applicable law, and circumstances of the case determine the issues that arise in litigation.
That is another reason the administrative appeal deserves careful attention. Preparing for the possibility of litigation begins before a lawsuit is filed.
What Should You Expect When You Contact Hawks Quindel, S.C.?
You do not need to understand ERISA or diagnose every problem with the insurer's decision before contacting us.
Begin by telling our team about the denial and completing the intake process. Having the denial letter available is particularly helpful because it can identify the insurer's reasoning, the appeal procedure, and important deadlines. Other useful documents may include your disability policy or Summary Plan Description and correspondence concerning the claim.
Our team can then determine whether your matter qualifies for a free case screening. If our attorneys are able to assist, they can explain the representation process, applicable fees, and the next steps before you decide how to proceed.
Frequently Asked Questions About LTD Denials and Appeals
Should I appeal my LTD denial myself before contacting a lawyer?
You do not need to file an appeal before seeking legal advice. Because the administrative appeal is an important opportunity to develop evidence, consider having the denial reviewed before submitting a response, particularly when an ERISA plan is involved.
Can I send new medical evidence with my LTD appeal?
Yes. Department of Labor guidance specifically instructs claimants to submit additional information or evidence they want the plan to consider during an appeal. The evidence should address the reasons for the denial rather than simply increasing the volume of the claim file.
Can I obtain the insurer's records before appealing?
For ERISA-governed claims, the plan must provide relevant documents, records, and other claim information upon request and without charge. A claimant may also request identification of medical or vocational experts whose advice the plan obtained.
How long does an insurer have to decide an ERISA disability appeal?
The Department of Labor guidance states that disability appeals generally must be decided within a reasonable period, but no later than 45 days after the plan receives the appeal. Special circumstances may permit an extension of up to an additional 45 days when the plan provides the required notice.
What if I already missed my LTD appeal deadline?
Do not assume that nothing can be done, but seek legal advice promptly. The available options depend on the plan, the reason the deadline was missed, the insurer's procedures, and other circumstances. Missing a required administrative appeal deadline can create significant obstacles to later pursuing benefits.
Talk to a Long-Term Disability Attorney at Hawks Quindel, S.C. to Learn More
An LTD denial does not necessarily mean you have reached the end of your claim. It does mean that you have reached a stage where deadlines, evidence, and the way the appeal is prepared can have lasting consequences.
Our attorneys can review your denial letter, policy, claim history, and the insurer's stated reasons for denying benefits. We can determine what evidence may strengthen the administrative record and pursue the claim through appeal and, when appropriate, litigation.
Contact Hawks Quindel, S.C. to begin the intake process and learn whether your matter qualifies for a free case screening. Call our Madison office at 608-257-0040 or our Milwaukee office at 414-271-8650, or fill out our confidential contact form.