Many LTD claimants whose claims get denied plan to handle an appeal on their own and then involve an attorney if the insurer denies their appeal. On the surface, it seems like a good way to save money on legal fees. In reality, it can be one of the most costly decisions in the entire process.
If your claim is governed by ERISA (the Employee Retirement Income Security Act of 1974)—which most employer-sponsored group LTD policies are—the evidence that can be used in your case is likely locked in once the insurer makes the final decision on your appeal.
The Closed-Record Problem
In most ERISA LTD cases, the court is stuck reviewing a closed administrative record. That means the judge looks at the claim file exactly as it existed when the insurance company made its final decision. This means once the appeal process is over, no new medical records, no clarifications from your treating providers, and no live testimony from you can be put in front of the judge. Essentially, if it’s not in the file at the time of the final denial, the judge won’t see it.
Building the Case in Court Requires Strong Raw Material
The litigation stage is the time for a claimant’s attorney to present all of the facts and legal arguments in a way that tries to persuade the judge that the insurance company’s denial was wrong. But much like building a house, the structure is only as strong as the materials it’s built from. A skilled ERISA attorney can work with what’s in the record and sometimes persuade the court to send the case back to the insurer for another review; however, if key pieces of the foundation are missing, the case usually doesn’t hold up.
How Small Gaps Kill Otherwise Good Cases
Especially because the insurance company’s decision generally has to be awarded significant deference by the court, even a seemingly minor gap or error in the record can be enough to give the insurance company a win. A few of the most common issues in cases that didn’t have an attorney assisting with the appeal are:
- Barebones medical records with no detailed opinions from treating providers on work restrictions;
- Errors or out of context notes in medical records (such as saying that a patient improved), without sufficient explanation;
- Gaps in treatment or lack of escalation of care without explanation; and
- A lack of a clear medical connection between symptoms and an inability to perform relevant job duties.
The insurance company doesn’t necessarily have to prove that you’re not disabled. They just need enough in the record to show that their decision was reasonable.
“We’ll Fix It in Court” Doesn’t Work Here
I sometimes speak with potential clients who aren’t too concerned about the appeal process because they figure once they get the chance to speak with a judge and explain their condition, or have their treating providers testify, they’ll win in court. This is a common but dangerous assumption for ERISA LTD cases. Because there is generally no trial for these cases and no ability to submit new information, you’re usually stuck with the record you already have. You’re not proving your case from scratch in court, but rather arguing about whether the denial was reasonable based on that record. If the file is thin, inconsistent, or missing key pieces, you’re fighting uphill.
Appeals Actually Matter (A Lot)
The appeal is not a box to check. It’s your last real chance to fix the record.
A strong appeal should:
- directly respond to every reason for denial
- fill in gaps in the medical evidence
- get clear, functional opinions from treating providers
- provide clear objective medical evidence of limitations
- tie everything back to the job requirements
A skilled ERISA attorney will treat the claim process like litigation from day one.
If you are facing an LTD denial and want to discuss your next steps, contact our team today to review your denial and appeal strategy.