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    The Administrative Appeal Stage for Long-Term Disability Claims

    The Administrative Appeal Stage for Long-Term Disability Claims

    The administrative appeal stage is a critical part of the long-term disability (LTD) claim process. It offers claimants a chance to challenge an insurance company’s denial of an initial claim, if one occurs.

    Insurance companies closely review claims during this stage and may still issue a denial. However, understanding the administrative appeal stage and how to strengthen a claim that an insurer denied can raise the chances of success.

    In this article, Chisholm Chisholm & Kilpatrick (CCK Law) will discuss:

    • What the administrative appeal stage is
    • Key steps claimants should know about the appeal process
    • Ways LTD claimants can strengthen their appeal
    • What to expect after filing an administrative appeal
    Who We Are: Chisholm Chisholm & Kilpatrick is a nationally leading interest law firm based in Providence, Rhode Island. Since 1999, we’ve been helping long-term disability claimants get the benefits they need through claim assistance, appeals, litigation, and education.

    What Is the Administrative Appeal Stage?

    The administrative appeal stage is typically the second phase of the LTD claim process. It occurs when a claimant’s initial claim receives a denial. Claimants have the right to challenge this decision. The appeal stage allows LTD claimants to submit a formal appeal and provide new or updated evidence that supports their claim.

    How Long-Term Disability Administrative Appeals Work

    As CCK Law Managing Attorney Leah Small says, “When someone’s long-term disability benefits are denied or later terminated after an initial approval, they have the right to appeal that decision with the insurance company, and, essentially, the goal of that is trying to overturn the denial or termination of benefits.”

    What Are Some Common Reasons Insurance Companies Deny LTD Claims?

    Insurers often deny initial LTD claims. Some common reasons insurers deny initial claims include:

    Wrongful denials can occur due to administrative errors. It is important to review the denial carefully before submitting a strong appeal.

    Note: An insurance company may still deny an administrative appeal. In this scenario, you may wish to file a lawsuit. Litigation can be difficult, especially under ERISA. For more information, read our article on litigation and long-term disability insurance.

    What Are the Key Steps in Filing an Administrative Appeal?

    Filing an administrative appeal for a long-term disability claim involves several important steps that can significantly affect the outcome of a case. These steps include:

    • Review the denial letter: Carefully examine the insurance company’s claimed reasons for denying the claim.
    • Make note of filing deadlines: Administrative appeals must be filed within a set period. Typically (under ERISA), this period is 180 days from the date of the denial. Missing a deadline can prevent a claimant from receiving benefits and/or seeking legal action.
    • Request a copy of your c-file: A claimant’s “c-file” is all the information their insurer has on them and their claim. Claimants have the right to this file in ERISA-governed claims, but they must request it; i.e., an insurance company will not just give it to them. This file can be exceptionally large, so it is important to request it early in the appeal process.
    • Collect and submit additional evidence: This may include updated medical records, any relevant correspondence, evaluations, vocational evidence, and reports from your doctors.
    • Write a comprehensive appeal letter: The letter should include all gathered evidence, directly address the reasons for the denial, and explain why the decision should be overturned.
    If their claim is governed by state law, claimants often can bypass the appeal stage and file a lawsuit if they choose. However, for several reasons, it can still be a good idea to file an appeal first anyway. In claims governed by ERISA—like those under most employer-issued LTD policies—claimants must file an appeal before filing a lawsuit.

    What Are 4 Ways to Strengthen a Long-Term Disability Appeal?

    Submitting a strong administrative appeal is vital for claimants trying to overturn a long-term disability denial. Taking specific steps can help build a stronger case and increase the chances of success.

    Ways to strengthen a long-term disability appeal include:

    1. Engage experts to bolster the claim. Depending on the insurance company’s reason for the denial, claimants should not rely solely on their own understanding of their condition. They should enlist medical professionals to provide detailed evaluations of their health and how it impacts their ability to perform their job. Vocational experts can further strengthen their case by objectively assessing how their disability affects their capacity to work in their specific field or any occupation. Their specialized knowledge can add credibility to the appeal and provide valuable insights for the insurance company’s review.
    2. Proactively address common denial tactics. Claimants should familiarize themselves with the strategies insurance companies often employ to deny claims. This includes understanding how they might use surveillance, potentially biased medical reviews, or preexisting condition exclusions to justify their decisions. By anticipating these tactics, LTD claimants can prepare counterarguments with evidence and legal support to demonstrate the unfairness or inaccuracy of the insurer’s assessment.
    3. Leverage ERISA rules for a fair review process (if applicable). If the Employee Retirement Income Security Act of 1974 (ERISA) governs their LTD claim, then claimants must understand how this federal law provides specific regulations to protect their rights. These rules ensure a fair and thorough review of the appeal, but insurance companies often take advantage of ERISA. Thus, claimants need to familiarize themselves with ERISA to hold the insurance company accountable for its actions.
    4. Seek professional guidance from a Long-Term Disability Attorney. Navigating the complexities of a long-term disability appeal can be challenging. An experienced LTD lawyer can be an invaluable asset. They can guide you through the process, assist with gathering and presenting evidence, effectively counter denial tactics, and ensure that the claimant’s rights are being protected under ERISA. Their knowledge can improve a person’s chances of a successful appeal.

    What Can LTD Claimants Expect After Filing an LTD Administrative Appeal?

    After filing an administrative appeal for a long-term disability claim, it is important to know what to expect during the review process.

    Disability Insurance Company Deadlines: Why They Matter For Your LTD Claim

    Some important aspects of the LTD appeal review process include:

    • Insurance company deadlines: Timelines for an appeal vary, but under ERISA, an insurance company must make a decision within 45 days. However, they can—under certain circumstances—take a 45-day extension. In certain situations, tolling may be allowed.
    • Paper Reviews by doctors: One of the most common things insurers do is have a doctor do a paper review of the claim.
    • Further surveillance: As with the initial claim, insurers may conduct further surveillance on a claimant—both in person and online—to find reasons to deny the appeal.
    • Independent medical exams: An insurance company may request claimants attend an IME, but these exams are not always “independent” as the name implies. Rather, IMEs are typically administered by a doctor paid by the insurance company.
    • Receiving a decision: At the end of the process, the insurance company will either approve or deny the claim. In some cases, the insurer may ask for more information before making this final decision.

    Receiving a denial of an administrative appeal can be stressful, but claimants do have options if their appeal is denied. Filing a lawsuit—both under ERISA and state law—is often the next step. Arbitration may also be an option.

    It is crucial to keep track of the statute of limitations for legal action, as missing this deadline can prevent further action.

    Under ERISA-governed claims, if an insurance company obtains new evidence during its appeal review and intends to deny the appeal on that basis, it must give the claimant an opportunity to review and respond to that new evidence prior to making the decision.

    Frequently Asked Questions

    What should I submit with my appeal?

    You should include all supporting evidence, such as updated medical records, expert opinions, vocational assessments, and any other documentation that strengthens your case. Adding thorough evidence now helps ensure the record is as complete as possible before moving forward.

    Why is this stage so important?

    Because in many cases, an administrative appeal is your last chance to add evidence to the record. Once you move to litigation, the court usually only reviews the evidence submitted during this stage, making it critical to present the strongest appeal possible.

    Can I submit new evidence during the appeal?

    Yes. The administrative appeal is your main chance to strengthen the record with additional medical and vocational evidence. This step is often the deciding factor in whether a denial can be overturned.

    What happens if my administrative appeal is denied?

    If the insurance company upholds the denial, your next option is to file a lawsuit in federal court under ERISA. At that point, your case will be reviewed by a judge rather than the insurer.

    Need Help? Call CCK Law

    The long-term disability administrative appeal can be overwhelming, but it isn’t something you must handle on your own.

    CCK Law has:

    • Over 25 years of experience
    • Helped claimants at all stages of the process—claims, appeals, and litigation
    • Fought against all major insurance companies in the United States

    Contact Us

    • Call (800) 544-9144 for a free case evaluation
    • Fill out an online form
    • Our team will review your case and determine how we can help.
    Why LTD Claims Get Denied