Appealing an ERISA Long Term Disability Denial

1) Confirm your plan is governed by ERISA

ERISA generally applies to private‑sector, employer‑sponsored LTD plans—not to government or most church plans, and not to individual disability policies bought directly.

2) Calendar the deadlines that control your appeal

• Your deadline to appeal: You typically have at least 180 days from the date of the denial letter to submit a written appeal.
• Insurer’s deadline to decide your appeal: The plan must decide within 45 days, with one possible 45‑day extension for “special circumstances” (with written notice).
• Initial claim timing (for context): LTD “disability claims” decisions are due in 45 days, with up to two extensions (30 + 30) if properly noticed; time can be tolled while they await information from you.

3) Use your right to a “full and fair review”

ERISA regulations require a full and fair review on appeal—meaning detailed denial reasons, access to your entire claim file, and the right to see and respond to any new medical or vocational evidence before a final decision. These rules also require independence and impartiality of decision‑makers for disability claims.

Promptly request (in writing) the complete claim file and the policy/summary plan description, then ask the administrator to disclose any internal rules or guidelines relied upon.

4) Build the administrative record—this may be your last chance

Federal courts usually decide ERISA benefit suits based on the administrative record that existed when the plan finished your appeal—so put everything in now: updated medical records, supportive treating‑physician opinions, medication side‑effects, functional capacity evidence, vocational analysis tying symptoms to your actual job duties, and credible third‑party statements.

5) Spot (and document) procedural errors that can help your case

2018 DOL updates strengthened claimant protections: denial letters must be more specific; administrators must let you see and rebut new evidence or rationales before denying an appeal; they must ensure impartiality; and they must clearly disclose litigation deadlines. Serious non‑compliance can allow a claimant to treat remedies as “deemed exhausted” (i.e., proceed to court) or trigger de novo judicial review in some courts.

6) Know the standard of review (it can be outcome‑determinative)

• Under Firestone v. Bruch, courts review benefit denials de novo unless the plan grants the administrator discretionary authority—if it does, courts generally apply a deferential standard.
• Under MetLife v. Glenn, a built‑in conflict of interest (when the insurer both decides and pays claims) is a factor courts weigh against the plan’s decision.
• In the Second Circuit (covering New York), Halo v. Yale rejected “substantial compliance”; to keep deference, plans must strictly follow ERISA claim‑procedure rules or show any slip was inadvertent and harmless—otherwise courts apply de novo review.

A claimant‑oriented appeal checklist

• Write right away to request the claim file and all rules/guidelines relied upon. Ask to be sent any new medical or vocational reviews before a final decision so you can respond.
• Create a cohesive medical narrative: treating‑provider letters that translate diagnoses into functional limits, explain variability of symptoms, and address perceived “inconsistencies.”
• Vocational proof: a job‑demands analysis and (where helpful) an expert opinion connecting your restrictions to the material duties of your own occupation (or “any occupation,” if applicable).
• Address insurer critiques head‑on: IME/peer‑review rebuttals, clarifying data (e.g., arrhythmia logs, medication side‑effects), and explanations for normal exam findings that don’t reflect work capacity.
• Meet the 180‑day deadline with a complete package**—**don’t rely on a short letter promising more later.
• Preserve issues: note any missed deadlines, vague rationales, failure to share new evidence, or impartiality concerns—these can affect the standard of review later.

Why this matters

A strong administrative appeal maximizes your chance of reversal and—if litigation becomes necessary—sets up the most favorable record and standard of review under ERISA.

Published by the Law Office of Justin C. Frankel, P.C. — claimant‑side insights for navigating ERISA LTD appeals. This article is for informational purposes only and should not be construed as legal advice.

Justin C. Frankel  is the founder of the Law Office of Justin C. Frankel, PC, a Long Island, New York headquartered law firm representing clients nationwide in disability insurance claims. For more educational information please go to our website www.jfrankellaw.com.

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