TBI and Long-Term Disability: What Claimants Should Know
A traumatic brain injury, or TBI, may qualify a person for long-term disability (LTD) benefits when the injury prevents them from performing the material duties of their own or any occupation under the terms of their insurance policies.
Many TBI symptoms, including memory loss, slowed processing speed, and trouble concentrating, are not visible to others, which can make these claims harder to document and easier for insurers to dispute.
This article explains how LTD policies define disability for a TBI, what medical evidence typically supports a claim, common reasons insurers deny or terminate these claims, and what steps a claimant can take if their benefits are denied.
What Is a Traumatic Brain Injury (TBI)?
A traumatic brain injury (TBI) occurs when a sudden blow, jolt, or penetrating injury disrupts normal brain function. Common causes include falls, motor vehicle accidents, assaults, and sports-related injuries. Physicians generally classify TBIs as mild, moderate, or severe, depending on factors such as loss of consciousness and imaging findings.
Even a mild TBI, sometimes diagnosed as a concussion, can cause lasting cognitive and physical symptoms that can negatively impact your ability to work. According to the Centers for Disease Control and Prevention (CDC), TBI-related hospitalizations and deaths affect hundreds of thousands of people in the United States each year, and older adults face some of the highest rates of both.
TBIs can cause a wide range of symptoms, including:
- Memory loss
- Slowed processing speed
- Difficulty concentrating
- Chronic headaches
- Dizziness
- Mood changes
Many of these symptoms are considered invisible impairments because they do not always appear on standard imaging, such as a CT scan or an MRI. This distinction matters later in the claims process, since insurers often expect objective proof of a disabling condition. Some claimants with a moderate or severe TBI may also qualify as having a catastrophic injury under their policy, which can affect certain benefit provisions.
Watch the CCK Law partner Leah Small discuss traumatic brain injury claims:
How Do Long-Term Disability Policies Define Disability for a TBI?
Most employer-provided long-term disability policies pay a percentage of a claimant’s pre-disability earnings when a TBI prevents them from performing the material duties of their own or any occupation. These employer-sponsored plans are typically governed by the Employee Retirement Income Security Act (ERISA), a federal law that sets rules for how insurers must handle disability claims and appeals.
Most LTD policies also apply two different definitions of disability over the life of a claim. Usually for the first 24 months, a claimant generally needs to show they cannot perform their own occupation. After that point, many policies shift to an any occupation standard, which asks whether the claimant can perform any job for which they are reasonably qualified based on their education, training, and experience.
Understanding a policy’s specific language is an important early step even before an initial claim is filed, since the exact terms can vary from policy to policy.
What Medical Evidence Do You Need to Support a TBI Claim?
Insurers generally expect medical evidence connecting a TBI to specific functional limitations that prevent a claimant from working. Because many TBI symptoms are considered invisible impairments, thorough and consistent documentation is essential.
| Type of Evidence | What It Documents |
| Neuropsychological evaluation | Measures deficits in things like memory, attention, processing speed, and executive functioning |
| Medical records | Documents the injury and its severity, its diagnosis, ongoing symptoms, test results, treatment history, and more. |
| Imaging (CT or MRI) | Can identify structural brain damage in moderate to severe TBI cases, though imaging often appears normal after a mild TBI |
| Attending physician statement | Documents the treating physician’s assessment of functional restrictions and limitations |
| Functional capacity evaluation | Connects a claimant’s physical limitation to the specific demands of their job. |
Claimants should also keep detailed logs of how their symptoms affect daily activities, since TBI symptoms can fluctuate over time. Statements from family members, coworkers, and treating providers can offer additional context for these limitations.
Why Do Insurers Deny or Terminate TBI Long-Term Disability Claims?
Insurance companies frequently deny or terminate TBI claims, even when a claimant’s impairments are well documented. Common reasons for denial include the following.
- Reliance on normal imaging — Some insurers point to normal or inconclusive CT or MRI results as a reason to deny a claim, even when neuropsychological testing documents significant cognitive deficits.
- Condition improvement — Insurers may argue that TBI symptoms can improve within a certain amount of time and that, consequently, you should be capable of going back to work.
- Independent medical exams and file reviews — Insurers may rely on an independent medical exam performed by an examiner who never previously treated the claimant, or on a review of the file alone, to dispute the treating physician’s findings.
- Failure to meet the any occupation standard — After 24 months, an insurer may argue that a claimant can perform some other type of work, even if they cannot return to their prior occupation.
- Surveillance — Insurers sometimes hire investigators to conduct surveillance on claimants and may use brief moments of activity to suggest a claimant is not as impaired as reported.
A more complete discussion of these tactics is available on CCK Law’s page addressing why insurers deny long-term disability claims.
What Should You Do If Your TBI Long-Term Disability Claim Is Denied?
A claimant who receives a denial should carefully review the denial letter and the terms of their policy before responding. The following steps can help build a stronger appeal.
- Request the complete claim file — Ask the insurer for all documents and records used to evaluate the claim, including any independent medical exam or file review reports.
- Gather updated medical evidence — Consider new neuropsychological testing, updated medical records, reports from treating doctors, and other updated evidence if the claimant’s functioning has changed since the initial decision.
- Consider a vocational evaluation — A vocational expert can help address how a claimant’s limitations relate to the demands of their own or any occupation.
- Submit a written appeal on time — Most ERISA-governed plans set a 180-day deadline to file an internal appeal after a denial.
Because most employer-provided LTD plans are governed by ERISA, claimants generally must complete the insurer’s internal administrative appeal before filing a lawsuit. Reviewing the applicable filing deadlines early can help avoid missing this window. If an appeal is unsuccessful, a claimant may consider litigation. A more detailed discussion of these options is available on CCK Law’s page about what to do if your long-term disability claim is denied.
How Long Can You Receive LTD Benefits for a TBI?
The length of time a claimant can receive LTD benefits depends on the terms of their policy, including the maximum benefit period and whether the claimant continues to meet the applicable definition of disability.
Even if benefits continue, the amount a claimant receives may change over time. For example, a claimant receives Social Security disability benefits, since many policies reduce the monthly LTD payment by some or all of that additional income. More information on how these two benefit programs interact is available on CCK Law’s website, along with a broader discussion of long-term disability offsets.
Watch CCK Law’s Managing Partner Mason Waring and Partner Leah Small discuss long-term disability offsets:
Frequently Asked Questions
Does a mild TBI or concussion qualify for long-term disability benefits?
The severity label alone does not determine eligibility. A mild TBI can qualify for benefits if it causes ongoing functional limitations that prevent a claimant from performing their job duties. What matters is how well the claimant’s symptoms and limitations are documented.
What if my brain imaging came back normal?
Normal imaging is common after a mild TBI and does not rule out a disabling condition. Neuropsychological testing and detailed documentation of cognitive symptoms can help establish a claim even without abnormal imaging results.
Can my long-term disability benefits be reduced if I also receive Social Security disability benefits?
Many LTD policies include an offset provision that reduces the monthly LTD payment by some or all of a claimant’s Social Security disability benefits. Reviewing the policy’s offset language can clarify how this applies to a specific claim.
How long do I have to appeal a denied TBI long-term disability claim?
Most ERISA-governed LTD plans set a 180-day deadline to file an internal appeal after a denial. Reviewing the denial letter and plan documents can confirm the exact deadline that applies to a specific policy.
Can depression or PTSD that developed after a TBI support my claim?
Conditions such as depression or post-traumatic stress disorder that develop after a TBI can be considered alongside the brain injury if properly documented. A treating physician’s records can help establish how these conditions affect a claimant’s ability to work.
How CCK Law Can Help
Claimants pursuing long-term disability benefits for a TBI should be proactive in documenting their symptoms and understanding the terms of their policy. If you need assistance with a long-term disability claim or appeal involving a TBI, CCK Law may be able to help. Since 1999, we have assisted claimants in pursuing long-term disability benefits, though past results do not guarantee future outcomes.
Contact us today for a free case evaluation, by phone at (800) 544-9144, or through the online form on our website.
